Pelvicring disruption (PRD) requires considerable forces and usually occurs in polytraumatized patients(pt).

The purpose of this study is to analyze radiologic results and functional outcome of PRD in polytraumatized pt.

Material and Methods: Of 226 pt with PRD, 78% (176) were polytraumatized, and they are the subject of this study. Mean age was 38.8 years (11.4–85.8). There were 102 men and 74 women. The cause of injury in 69% was traffic accident; fall from a great height in 16.4%; accident at work in 8.6% and miscellaneous in 6%. The incidence of involvement of other systems was: musculosceletal-78%; respiratory-58%; CNS-51%, intestinal-32%, urinary-14%; cardiovascular-8%. The average ISS was 34; 56 pt (32%) were haemodynamically unstable. According to M. Tile’s classification, 101 were found type B (B1-48; B2-30; B3-23) and 75 type C (C1-49; C2-18; C3-8). Perioperative mortality was 6% in B-type and 15% in C-type fractures.

Immediate resuscitation started at admission and was followed by staged treatment. Life-saving surgery and provisional stabilization of pelvis were performed as a top priority (first stage). Management of associated lesions (second priority) was the next stage. The last stage was open reduction and internal fixation of PRD in 102 pt, external fixation in 46 pt and combined fixation in 28 pt.

Results: X-ray follow-up results were excellent in 66%, good in 16%, fair in 10% and poor in 8%.

The best X-rays results were in type B1-94%; B2/B3-76% and C-63%.

Functional results were excellent in 48%, good in 32%, fair in 12% and poor in 8%. The best functional results were in type B2/B3 -90%; B1-73% and C-70%.

Conclusion:

Determination of priorities of surgery is essential in the management in polytraumatized patients with PRD especially in the early period.

Background: Treatment of patients with partially or totally unstable pelvic ring disruptions includes primary anterior stabilization with an external fixator and additional posterior internal fixation. Iliosacral screws placed percutaneously under fluoroscopy or navigation guided techniques are widely accepted today to address the posterior lesions. Definite surgery is usually performed on a semi-emergent basis, whereas a delay of more than seven days in definite fixation is accompanied by a high rate of pulmonary complications, malreduction and infections. Purpose: To compare the outcome of patients with type B and C pelvic ring disruptions treated with immediate definite posterior fixation (within 24 hours) as compared to those treated with early fixation (24–96 hours from arrival). Patients and Methods: The medical records of 44 patients with type B and C pelvic ring disruptions were reviewed retrospectively. All posterior lesions were treated with closed reduction and internal fixation with percutaneously placed posterior iliosacral screws. Patients were divided into two groups, based on the time of definite fracture fixation from admittance to the ER. Immediate treatment included patients treated within 24 hrs of arrival (Group A), early intervention was defined as definite fracture fixation between 24–96 hrs from the patient’s arrival (Group B). Post operative radiographs (Pelvis AP, inlet and outlet) were used to assess the quality of final fracture reduction. Patient records were screened for demographic data, injury severity score and early morbidity and mortality. Results: Forty-four patients were treated between the years 1999–2002 due to posterior pelvic ring fractures. 70.5% of the patients were male, the majority of patients (41/44) were injured during motor vehicle accidents, two patients sustained work-related crush injuries and one patient was injured during a suicide attempt. Fracture patterns were classified according to the Tile classification, there were 31 type B and 13 type C fractures. Thirty patients were treated within 24 hrs of admittance to the ER (group A), fourteen were treated between 24 and 96 hrs from arrival (Group B). ISS averaged 19.5 in group A as compared to 17.8 in group B (p=0.74). Overall complication rates were low. Malreduction was noted in one patient (group A), one patient in each group became infected, S1 foraminal penetration occurred in two patients (Group A). Two patients in group A died due to complications not related to the orthopedic intervention. No significant difference was found between the complication rates in both groups (p=0.34). Conclusions: Immediate definite fixation of posterior pelvic lesions can be safely performed with posterior iliosacral screws. Comfortable nursing and early mobilization can be achieved without compromising the quality of fracture reduction and minimizes post-operative complications

Introduction Pelvic ring disruptions have well established biomechanical forces that correlate with fracture pattern. These patterns have considerable soft tissue and ligamentous disruptions associated with high velocity vectors which result in unstable injuries. This study critically evaluates the functional outcome of anatomically and or haemodynamically unstable pelvic ring disruptions treated with operative management and presents a retrospective analysis of injury pattern, surgical therapy and complications in surgically treated Tile B and Tile C disruptions. Methods This study is a retrospective review of results of the operative management of pelvic fractures at the Alfred Hospital, Melbourne over the period of May 1997 to May 2001 (one to four years) using the Iowa Pelvic Score (Martin-American Academy Meeting 1999) to assess functional outcome. Initial screening resulted in 204 patients with pelvic disruptions via DRG coding. Of this 65 patients were managed operatively and only 34 patients were subquently included in the study. Exclusion criteria were; residual cognitive defect, hip or ace-tabular injury, spinal injury with neurological deficit, repeat trauma or ongoing litigation. The inital data gathered included; age, sex, type of accident, Tile classification, neurological injury, urogential injury, type of treatment, adequacy of treatment, post-operative complications, length of hospital and stay in rehabilitation. A follow-up survey was performed for each of these patients by telephone to obtain a post-operative functional outcome score. Thirty two of the 34 patient were able to complete the survey. Results Thirty-four patients were included in the study with 29 (85%) males and five (14%) females. The modes of injury were as follows: five motor car occupants, 13 motorbike riders, three pedestrians struck by motorcar, three falls, three occupational and seven other. Twenty-seven were classified as Tile B and seven Tile C. These fractures were treated with the following; external fixation alone was used in four patients, external fixation followed by anterior plating was used for 18 patients, anterior plating and posterior ilio-sacral screws were used for nine patients, three patients received both anterior and posteior plate fixation. The mean number of operations to stabilize the disruptions was two. The major complication incurred by most of the patients was pin site infection. The mean length of hospital stay was 25 days and the mean length of rehabilitation stay was 35 days. Of the 32 patients interviewed all had function outcome scores greater than 70 (good). Most (n=13) of them returned to full time work. All reported cosmetic changes in their pelvis. Conclusions We feel that this study provided good quality retrospective data for the demographics and surgical therapy used to stabilize pelvic ring disruptions that are unstable. These results were consistent with current belief that internal fixation of pelvic fractures produced good functional outcome

Purpose: To describe operative experience and reductions of pelvic ring fractures treated with a novel pelvic reduction frame. Method: All patients with displaced pelvic ring disruptions treated with the pelvic reduction frame were included. The series includes 35 patients, with 34 acute fractures and one malunion. Pre-operative and immediate post-operative radiographs were reviewed, and maximal displacement measured using two reproducible methods. Procedure and injury data were also recorded. Results: In our series of 35 patients, we had 19 vertical shear fractures and 16 compression injuries. Mean age was 33.5 + 2.4, and mean delay to surgery was 4.7 + 0.6 days. Mean operative time in isolated procedures was 103.4 + 6.5 minutes. All but one patient had iliosacral screws placed, 18 had anterior column screws, six had symphysis plates and 12 had anterior external fixators. Maximum horizontal or vertical displacement was improved from 30.8 + 2.7 mm to 7.1 + 0.7 mm. Diameter asymmetry as measured on the AP view was improved form 26.4 + 2.7 mm to 5.2 + 0.7 mm. Very good, good or fair reduction was obtained in all acute cases. There was no statistically significant impact of obesity, fracture type or delay to surgery on quality of reduction (p> 0.05). Conclusion: This novel pelvic reduction frame is a powerful tool in the effective reduction and fixation of displaced acute pelvic ring disruptions

Aim: To establish a method of emergency and definitive stabilisation of Type C pelvic ring injuries. Methods: Patients with pelvic ring disruption were treated acutely, using instrumentation developed by Dr. Charles Reinert. Patients were positioned supine on a radiolucent operating table configured to allow the C-arm of an image intensifier to swing through an arc sufficient to allow pelvic inlet and outlet views of the pelvis. The unstable hemipelvis was reduced by means of longitudinal traction on the leg and lateral compression with a spiked, long handled, cannulated guide. Guide wires could be positioned accurately through the guide, allowing accurate placement of AO 7.3 mm cannulated iliosacral screws, by minimally invasive percutaneous techniques. Results: Successful acute biomechanical pelvic stabilisation was achieved in all cases. After a short learning curve, the procedure could be completed in 20 minutes. Discussion: Previously, pelvic stabilisation was often achieved by initial, tentative stabilisation using pelvic slings, traction and external fixation, with or without later definitive fixation. Using minimally invasive techniques, rapid, emergency stabilisation can be achieved, with sufficient stability to equally suffice for definitive fixation. The minimally invasive, percutaneous technique provides greater safety for treatment of patients with early coagulopathy. Conclusions: Acute, rapid and definitive stabilisation of type C pelvic ring disruption can be achieved by minimally invasive, percutaneous techniques using the Reinert instrumentation

The Stoppa approach was originally conceived to deal with difficult abdominal hernia surgery. Its use has been modified to deal with Acetabular and Pelvic surgery. We report on our use of the Stoppa approach in 26 cases from 1998–2003 to fix Pelvic, Acetabular, and combined Pelvic/Acetabular fractures. The Stoppa approach was used in combination with other approaches to afford the best access for fixation. 11 of the cases were Acetabular fractures with no pelvic ring disruption (42.3%), 4 cases (15.3%) were pelvic ring disruptions without an Acetabular component. The other 11 cases (42.3%) were combined Pelvic and Ace-tabular fractures where this approach came into its own. In particular it is to be noted that the Corona Mortis was easily identifiable in 5 (19.2%) of the cases to allow its safe ligation. The anatomy of the approach and the access afforded are considered, along with the plating techniques that can be achieved because of its use. Patients were followed up for an average of 17.39 months with one lost to follow up. Clinical results were excellent in 20 cases, good in 2, fair in 2, and poor in 1. Complications were lateral femoral cutaneous nerve palsy in 11 patients, 1 bladder rupture, 2 superficial wound infections, one lateral incisional hernia related to an ilioinguinal approach, and 1 deep vein thrombosis. Heterotopic Ossification occurred in 3 patients in whom the Kocher-Langenbeck approach was used. One revision for screw proximity to the joint was undertaken. The Stoppa approach allows safe access and ease of reduction and fixation in these complex fractures, in combination with other approaches, particularly in combined pelvic and Acetabular fractures. We outline our recommendations for its use in this paper and outline a series of fracture patterns where it is most helpful

The pelvic ring unstable disruptions are by itself life threatening and its stabilization is one of the priorities. On the other hand the surgical approach and internal fixation of this type of injuries represent a long and aggressive intervention, with high blood loss and complications. By these reasons a methodology that not only allows a precocious and less aggressive intervention with the possibility of stabilization of the posterior and anterior elements of the pelvic ring, and also the possibility to introduce postoperative corrections is indicated. In January 1999 we introduce in our Unit the treatment of pelvic ring fractures and disruptions with the association of Ilizarov frame and minimal invasive internal fixation. It is our intention to present the preliminary protocol of treatment and its results. Until 2002 we have treated 97 cases of pelvic ring disruptions. We have treated surgically 26 patients. From those, 10 cases were of open book and closed book injury type (2 pubic platting, 4 static external fixator and 4 dynamic Ilizarov frame) and 7 cases were of vertical shear injury type (4 pubic plating and sacro-iliac bar/ screw, 3 dynamic Ilizarov frame). Results were evaluated with our own protocol. Infection rate compromised final results of the cases treated by ORIF (4:6) and reduction was poorer with the static external fixator (2:4). Treatment with Ilizarov frame revealed 5 good results and 2 fair results. The authors conclude that even with a limited number of patients and follow-up, the use of the dynamic Ilizarov frame with a minimal invasive approach, showed to be a simple, fast and efficient method for the handling of serious fractures and disruptions of the pelvic ring, allowing a good stabilization of the anterior and posterior components, permitting the “fine tuning” in the postoperative period, without major complications

Summary. Application of RSA in supine and standing positions allows pelvic fracture stability to be measured more accurately than current techniques. RSA may enable a better understanding of these injuries. Introduction. The in vivo stability of the pelvic ring after fracture stabilisation remains unknown. Plain radiographs have a low accuracy in diagnosing loss of fracture reduction over time. Radiostereometric analysis (RSA) is an accurate imaging measurement method that has previously been applied to measure the healing of other fractures. This pilot study investigated the potential application of RSA in supine and standing positions to measure pelvic fracture stability over time and under weightbearing load. Methods. Five patients with a similar type C pelvic ring disruption who were all operated on using the same surgical technique and had RSA markers inserted at the time of surgery. All five patients had a unilateral comminuted sacral fracture lateral to the sacral foramina treated with posterior plating and pubic rami fractures stabilised by external fixation for six weeks. All patients were mobilised partial weight bearing after regaining leg control. RSA examinations at 2, 4, 12, 26 and 52 weeks included three radiographic pairs taken in supine, standing and supine positions at each time point. Two additional RSA examinations were performed the day prior and post pin removal at 6 weeks. Results. All patients ambulated before the 2 week follow-up and progressed uneventfully. At latest follow-up, there were no complications. Minimal displacements (translations less than 0.3mm and rotations less than 0.5°) were recorded between the supine exams pre and post standing at 2 weeks. Hence, the supine examination was found to be a reliable position to measure the migration of the ilium over time. No loss of reduction was identifiable on plain radiographs over time. At 52 weeks, in contrast to plain radiographic results, RSA measurements revealed that one patient had a fracture migration greater than 4mm. Such large displacements could result in sacral nerve root transection, leading to devastating consequences, such as incontinence, for patients whose sacral fractures are through or medial to the sacral foramina. In one patient, the migration recorded for the apparent uninjured posterior complex side exceeded the migration of the injured side suggesting an unrecognised bilateral injury. Comparative RSA examinations pre and post external fixator removal demonstrated that in three patients the injured hemipelvis migrated greater than 2mm after the removal of the external fixator, which may be indicative that the fixator was removed prematurely. Discussion and Conclusion. The application of RSA allows accurate measurement of pelvic fracture stability which is difficult, if not impossible, to identify and quantify with any other imaging techniques. Hence, RSA has the capacity to enable a better understanding of pelvic ring injuries and optimise their treatment

Objective: A floating hip, e.i. combination of pelvic or acetabulat fracture with ipsilateral femoral fracture is uncommon condition, but posing considerable problems such as how to manage each component of the injury and what are the treatment priorities. The aim of the syudy is to report our experience with surgical treatment of traumatic floating hip. Material and methods: For the 4-year period in our institution 15 patients with floating hips (10 mails, 5 females, average age 38 years) were treated operatively. There were 10 unstable pelvic ring disruptions B and C types and 5 displaced acetabular fractures, combined with 2 neck, 11 shaft and 2 supracondylar femoral fractures. Six patients were operated simultaneously for both components and in the rest definitive pelvic surgery were done at a second stage. pelvic girdle was stabilized by a variety of methods: anterior sacro-iliac plates, iliosacral lag screws, transsacral posterior plaates. Acetabular fractures were all treated by ORIF. For femoral fractures nailing was done in 8 cases, plating in 5 and cervical screw fixation in 2. Results: All fractures healed in time. Two superficial femoral infections resolved after local care. Results for pelvic injuries were estimated according to Pholemann score and for acetabular fractures – to Matta scale. In respect to pelvic fractures 5 ecxellent, 3 good and 2 poor results were noted, and regarding acetabular fractures 3 exccelent, 1 satisfactory and 1 poore results. All femoral fractures united in good position. Overall final outcome was excellent in 8, good in 3, fair in 1 and poor in 3 patients. Conclusions: Surgical treatment is a method of choice for a floating hip. ORIF of pelvic ring and locking nailing of the femur result in best outcome. Simultaneous procedure provides more rapid recovery, but should be carried out only in stable patients. If staged surgery is planned, stabilisation of the femur should be done prior to definitive pelvic fixation in order to facilitate later pelvic surgery

Purpose: To provide a CT-based description of the anatomic specifics of LC-1 pelvic ring disruptionsand to describe injury severity to other body systems, and their correlation with fracture anatomy. Method: We identified a consecutive series of 100 patients with Young and Burgess LC-1 pelvic ring disruptions. The CT scan was reviewed for each patient. Sixteen categories were reviewed for each patient. Sacral fractures were graded based on severity. The age, ISS, and six categories of AIS were recorded for each patient. A statistical analysis was performed to test the associations between fracture characteristics and injury severity. Results: All patients but three had one or more rami fractures, and all but two had a sacral fracture. Of the 98 anterior sacral injuries, there were nine (9.2%) buckles, 39 (39.8%) simple fractures, and 50 (51.0%) comminuted fractures. Of these 98 anterior sacral injuries, 47 (48.0%) were complete, passing through the sacrum and exiting the posterior cortex. Increasing severity of anterior sacrum fracture was associated with the presence of a complete sacral fracture (p value < 0.0001). Of the 98 sacral fractures, 50 (50.0%) were Denis type I, 41 (41.8%) Denis type II, and 7 (7.1%) Denis type III. Higher Denis types had higher likelihood of complete fractures of the sacrum (p value < 0.0001). There was a significant association between the presence of a comminuted rami fracture and a complete sacrum injury (p = 0.003), and a trend to higher rates in Nakatani two superior rami fractures (p = 0.169). There was a trend to higher mean ISS scores (p = 0.2287), and significantly higher abdominal AIS scores (p = 0.0014), in those with a complete sacral fracture. Those with comminuted and complete sacral fractures were more likely to be symptomatic and require posterior ring stabilization (p-value 0.003 and 0.043 respectively). Conclusion: LC-1 fractures of the pelvic ring represent a spectrum of injuries, with a large proportion having complete disruption of the sacrum. This complete injury of the sacrum is predicted by Denis type, severity of anterior ring disruption, Abdominal AIS, and potentially location of rami fracture and ISS. CT scanning best defines these injuries

Introduction: Type C pelvic ring disruptions are commonly associated with significant patient morbidity. It is the senior author’s (APP) experience that the sacro-iliac alar cartilage is commonly damaged at the time of initial trauma. If left untreated, this may give rise to post-traumatic arthrosis of the joint, with resultant pain. The natural history of type C disruptions is one of late pain. In this paper, we review our results of acute arthrodesis of the SI joint simultaneously with fixation of the posterior pelvis. Methods: From 1987–2000, a consecutive series of 28 patients who underwent primary surgical fusion and internal fixation of the sacro-iliac joint underwent clinical and radiographic review. All patients were examined at latest follow-up (79.8 months) in regards to pain, range of motion, walking tolerance and the incidence of significant complications. Evaluation of the pelvic ring reduction and success of arthrodesis of the SI joint were made through radiographs of the pelvic ring. In addition patients completed the SF-36 as a measure of general health status and the Musculoskeletal Function Assessment (MFA) and WOMAC scores as a measure of functional outcome. Work status was also examined. Results: The majority of these injuries were sustained in either motor vehicle crashes or high energy falls. There was a high incidence of associated injuries and co-morbidities. The male to female ratio was approximately 2:1 with a mean age of 27 years. At initial surgery, all patients were noted to have severe fragmentation and disruption of the alar cartilage. The majority of patients had sacro-iliac screw fixation for their posterior injury and an external fixator for anterior stabilization. At follow-up there was a low incidence of late posterior complex pain. All patients were independently mobile and there were minimal complications. Only 1 patient had to change jobs secondary to pelvic or low back pain. The functional outcome at long term follow-up was good with regards to the SF-36, MFA and WOMAC scores. Conclusions: Type C pelvic ring injuries have a high incidence of disruption of the alar cartilage. Treatment of these injuries by primary fusion and internal fixation leads to good long-term results

Introduction A complex challenge to trauma surgeon is the choice of clinical pathway management in hemodynamic unstable patients with pelvic ring disruption and potential intraperitoneal or other extrapelvic hemorrhage. Aim of the study In multi-trauma bleeding patients with pelvic ring injuries causing increased pelvic volume, the main source of hemorrhage is the fracture itself; in biomechanical stable the priority is to search and to treat extrapelvic sources of hemorrhage; CESCT is critical in the selection of appriopriate therapeutic approach in the case of bleeding pelvic injury. Material and Methods Patients admitted as major trauma are immediately evaluated by a multidisciplinary team in a dedicated room where ABC resuscitation, plain radiographs, abdominal ultrasound/DPL may be all performed. The comprehensive Tile pelvic disruption classification combines the mechanism of injury and the degree of pelvic stability. Previous works correlated pelvic fracture pattern with the risk of pelvic fracture hemorrhage. Classically, APC and VS mechanisms were associated with pelvic hemorrhage and LC mechanims with abdominal organ injuries. In this work we included in group A patterns of pelvic fracture where increased pelvic volume and major ligamentous disruption (Tile B1, B3 and C or APC and VS), Patterns of pelvic fractures with low risk of bleeding, such as those without ligament lacerations (Tile A) or with reduced pelvic volume (Tile B2 or LC) or isolated acetabular fractures, have been included in group B. Results Between October 2002 and January 2004, significant bleeding was observed in 87 of 142 pelvic fractures (61.26%). Thirty-seven of 87 (42.5%) had a pelvic fracture pattern attributable to group A and 50 to group B. All patients included had multiple sites of bleeding, but predominant hemorrhage from pelvic fracture was observed in 87% of group A patients and in only 6% of group B, while predominant hemorrhage from extra-pelvic sites was identified in 94% of group B and in only 13% of group A (p< .001). Conclusion Pattern of pelvic seems to be suggestive of the predominant site of bleeding; early application of measures of temporary pelvic stabilization should be considered a completion of resuscitation protocol; CESCT is the best diagnostic tool to choice the appropriate way to manage bleeding pelvic injuries and associated intraperitoneal injuries; availability of equipped CT scan and angiographic suitesand of short response time interventional radiologist is a crucial point for this diagnostic and therapeutic work-up

Introduction: Surgical treatment of unstable fractures of the pelvic ring is a well established technique both to stabilise the ring and reduce bleeding and to facilitate healing in an anatomic position and thereby facilitate rehabilitation. While the pathoanatomic differences between vertically and rotationally unstable fractures are well known, the purpose of this paper is to highlight the difference in expected outcome for these two injuries. Objective: To review the clinical and radiological outcome following operative treatment of unstable fractures of the pelvic ring and compare the outcome for type B and type C injuries. Design: Retrospective study of patients treated consecutively with review of initial admission notes and clinical and radiological follow-up. Patients: From January 1988 to July 1997, one hundred and sixteen patients were treated with traumatic disruption of the pelvic ring. Of these, ninety-five with type B or C fractures required definitive surgical stabilisation of their injuries, forty-five with Tile type B fractures and fifty with Tile type C fractures. There were sixty-three males and thirty-two females with an average age of thirty-three years. Intervention: All patients had operative treatment for definitive management of pelvic ring disruptions. Outcome measures: All patients were reviewed clinically and radiologically at a mean of fifty one months. Clinical review consisted of assessment of persistent pain, ability to ambulate, ability to return to work, clinical evidence of persistent instability of mal union. Radiological review was for evidence for mal union or non union. Results: At final review (mean fifty-one months) ninety-one patients were independently mobile. Of the four patients who required a stick or crutch, two had type B2.1 fractures and two had type C1.3 fractures. Three of these patients had associated acetabular fractures and this may have been contributory. Sixty patients were completely pain free at follow up. Seventeen patients complained of occasional mild pain after exercise but did not require analgesia. Eleven patients had moderate pain that occasionally required analgesia. Seven patients had severe causalgic type pain, all of who had had evidence of nerve injury at presentation. Only type C fractures with neurologic deficit at presentation had severe pain at follow up. Overall the incidence of pelvic pain, both anterior and posterior, was significantly higher in type C fractures. There were three non unions, all in type C fractures and one of these required surgery. There were fourteen mal unions, nine leg length discrepancies in type C fractures and five patients with a significant internal rotation deformity of greater than 15° in type B fractures. Conclusions: The outcome of surgical treatment of unstable pelvic fractures is worse following vertically and rotationally unstable fractures (type C) than after fractures that are only rotationally unstable (type B). This is valuable information when considering the prognosis for these injuries