We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries.

The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor.

External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries.

Unstable pelvic injuries in young children with an immature pelvis have different modes of failure from those in adolescents and adults. We describe the pathoanatomy of unstable pelvic injuries in these children, and the incidence of associated avulsion of the iliac apophysis and fracture of the ipsilateral fifth lumbar transverse process (L5-TP). We retrospectively reviewed the medical records of 33 children with Tile types B and C pelvic injuries admitted between 2007 and 2014; their mean age was 12.6 years (2 to 18) and 12 had an immature pelvis. Those with an immature pelvis commonly sustained symphyseal injuries anteriorly with diastasis, rather than the fractures of the pubic rami seen in adolescents. Posteriorly, transsacral fractures were more commonly encountered in mature children, whereas sacroiliac dislocations and fracture-dislocations were seen in both age groups. Avulsion of the iliac apophysis was identified in eight children, all of whom had an immature pelvis with an intact ipsilateral L5-TP. Young children with an immature pelvis are more susceptible to pubic symphysis and sacroiliac diastasis, whereas bony failures are more common in adolescents. Unstable pelvic injuries in young children are commonly associated with avulsion of the iliac apophysis, particularly with displaced SI joint dislocation and an intact ipsilateral L5-TP.

Cite this article: Bone Joint J 2015; 97-B:696–704.

Aims. This study aimed to analyze the correlation between transverse process (TP) fractures of the fourth (L4) and fifth (L5) lumbar vertebrae and biomechanical and haemodynamic stability in patients with a pelvic ring injury, since previous data are inconsistent. Patients and Methods. The study is a retrospective matched-pair analysis of patients with a pelvic fracture according to the modified Tile AO Müller and the Young and Burgess classification who presented to a level 1 trauma centre between January 2005 and December 2014. Results. A total of 728 patients with pelvic ring injuries were included, of whom 183 (25.1%) had a biomechanically unstable pelvic fracture. Of these patients, 84 (45.9%) had a fracture of a TP of L4 and/or L5. A total of 73 patients (13.4%) with a stable pelvic ring injury (p < 0.001) had a fracture of a TP. Patients with a fracture of a TP of L4 and/or L5 had a 5.5-fold risk (odds ratio (OR)) of having a biomechanically unstable pelvic injury. TP fractures (OR 1.6, p = 0.2) could not be confirmed as an independent predictor of haemodynamic instability. Conclusion. This is the first study that has demonstrated a positive correlation between a TP fracture of L4 and/or L5 and a biomechanically unstable pelvic ring injury. The presence of transverse process fractures of L4 and/or L5 indicates increased severity of pelvic injury and therefore can help in the planning of emergency treatment. Cite this article: Bone Joint J 2018;100-B:1214–19

Purpose of study. To review the treatment and outcomes of paediatric pelvic ring injuries in the UK. Methods and results. We performed a retrospective review of all pelvic fracture admissions to an English paediatric major trauma centre (MTC) from 2012 to 2016. A total of 29 patients were admitted with pelvic ring injuries with a mean age of 11 years (4- 16yrs). Road traffic accident was the mechanism in majority (72%), followed by fall from height (24%). Femoral shaft fracture was present in 5 (17%), head injury in 5 (17%), chest injuries in 5 (17%) and bladder injury in one child. 48% patients needed surgical procedures for fractures or associated injuries. We differentiated injuries according to the classification system of Torode and Zeig. 17% were Type A, 3% Type B, 48% Type C and 31% Type D. Almost all (93%) patients were treated conservatively. 51% of patients were allowed to mobilize full weight bearing after a period of bed rest. Non-weight bearing mobilization was recommended for fractures extending into the acetabulum, sacral fractures, unstable fracture patterns or associated fractures (neck of femur, femoral shaft and tibial shaft). Surgical fixation occurred in two patients. Both of these patients had significantly displaced Type D fractures. Only 44% of patients were back to sports at six months. Conclusions. Pelvic ring injuries are rare within the paediatric population and are associated with a high incidence of concomitant injury and significant functional morbidity. Their treatment should involve a multidisciplinary approach, which includes specialist in the care of pelvic trauma

We report the functional and socioeconomic long-term outcome of patients with pelvic ring injuries. We identified 109 patients treated at a Level I trauma centre between 1973 and 1990 with multiple blunt orthopaedic injuries including an injury to the pelvic ring, with an Injury Severity Score (ISS) of ≥ 16. These patients were invited for clinical review at a minimum of ten years after the initial injury, at which point functional results, general health scores and socioeconomic factors were assessed. In all 33 isolated anterior (group A), 33 isolated posterior (group P) and 43 combined anterior/posterior pelvic ring injuries (group A/P) were included. The mean age of the patients at injury was 28.8 years (5 to 55) and the mean ISS was 22.7 (16 to 44). At review the mean Short-Form 12 physical component score for the A/P group was 38.71 (22.12 to 56.56) and the mean Hannover Score for Polytrauma Outcome subjective score was 67.27 (12.48 to 147.42), being significantly worse compared with the other two groups (p = 0.004 and p = 0.024, respectively). A total of 42 patients (39%) had a limp and 12 (11%) required crutches. Car or public transport usage was restricted in 16 patients (15%). Overall patients in groups P and A/P had a worse outcome. The long-term outcome of patients with posterior or combined anterior/posterior pelvic ring injuries is poorer than of those with an isolated anterior injury. Cite this article: Bone Joint J 2013;95-B:548–53

Aim. Evaluate the outcome and complications of anterior pubic symphysis plating in the stabilisation of traumatic anterior pelvic ring injuries. Methods. All patients who underwent pubic symphysis plating in a tertiary referral unit were studied. Fracture classification, type of fixation, complications, and incidence of metalwork failure were recorded. Results. Out of 178 consecutive patients, 159 (89%) were studied for a mean of 41 months. There were 121 males and 38 females (mean age 38 years). Symphysis pubic fixation was performed in 105 AO-OTA type B and 54 type C injuries using a Matta symphyseal plate (n = 92), reconstruction plate (n = 65), or DCP (n = 2). Supplementary posterior pelvic fixation was performed in 103 patients. 6 patients required revision for failure of fixation or symptomatic instability of the pubic symphysis. A further 7 patients had metalwork removed for other reasons. Metalwork breakage occurred in 66 patients (42%), at a mean of 17 months. 64 of these 66 patients were asymptomatic and metalwork was left in situ. Conclusions. Plate fixation of the symphysis pubis is an effective method of stabilising anterior pelvic ring injuries with a low complication rate. There is a high rate of late metalwork breakage, but this is not clinically significant

Sacroiliac screw fixation is the method of choice for the definitive treatment of unstable posterior pelvic ring injuries; however this technique is demanding and associated with a high risk of iatrogenic neurovascular damage. We therefore evaluated the outcome, complications, surgical and fluoroscopy time for unstable posterior pelvic ring injuries managed with a transiliac locked compression plate. 23 patients were managed with a transiliac locked compression plate for unstable posterior pelvic injuries at a Level I Trauma Center. 21 patients were available for follow up after an average of 30 months and outcome evaluation was performed with the Pelvic Outcome Score, which is composed of a clinical, radiological, and social integration part. The overall outcome for the pelvic outcome score was excellent in 47.6% (10 patients), good in 19% (4 patients), fair in 28.6% (6 patients) and poor in 4.8% (1 patient). 15 out of 21 patients (71.4%) returned to their normal life, 3 patients (14.3%) were limited at work, and 3 patients (14.3%) were not able to return to work due to their disabilities. The social status was unchanged to the preinjury status in 19 patients (90.5%). 13 patients (62%) stated no changes in spare time and sports activities; 4 patients (19%) had minor and another 4 patients (19%) had major restrictions. The average operation time was 101 min and intraoperative fluoroscopic time averaged 74.2 sec. No iatrogenic neurovascular injuries were observed. Posterior percutaneous plate osteosynthesis may be a good alternative to sacral screw fixation because it is quick, safe, and associated with a good functional outcome

Crescent fracture dislocations are a well-recognised subset of pelvic ring injuries which result from a lateral compression force. They are characterised by disruption of the sacroiliac joint and extend proximally as a fracture of the posterior iliac wing. We describe a classification with three distinct types. Type I is characterised by a large crescent fragment and the dislocation comprises no more than one-third of the sacroiliac joint, which is typically inferior. Type II fractures are associated with an intermediate-size crescent fragment and the dislocation comprises between one- and two-thirds of the joint. Type III fractures are associated with a small crescent fragment where the dislocation comprises most, but not all of the joint. The principal goals of surgical intervention are the accurate and stable reduction of the sacroiliac joint. This classification proves useful in the selection of both the surgical approach and the reduction technique. A total of 16 patients were managed according to this classification and achieved good functional results approximately two years from the time of the index injury. Confounding factors compromise the summary short-form-36 and musculoskeletal functional assessment instrument scores, which is a well-recognised phenomenon when reporting the outcome of high-energy trauma

Various techniques have been used for the fixation of the posterior pelvis, each with disadvantages specific to the technique. In this study, a new protocol involving the placement of posterior pelvic screws in the CT suite is described and evaluated. A total of 66 patients with unstable pelvic ring injuries was stabilised under local anaesthesia with sedation. The mean length of time for the procedure was 26 minutes per screw. There were no technical difficulties or misplaced screws and no cases of infection or nonunion. All patients stated that they would choose to have the CT scan procedure again rather than a procedure requiring general anaesthesia. The charges for the procedure were approximately £1840 ($2800) per operation. CT-guided placement of iliosacral screws is a safe, feasible, and cost-effective alternative to radiologically-guided placement in the operating theatre in selected patients

Introduction. The aim of this study was to evaluate the health quality of life and return to sports activities following pelvic ring injuries. Patients and Methods. Between January 2006–2007 patients treated in our institution with pelvic fractures were eligible to participate. Inclusion criteria were adult patients. Exclusion criteria were children and pathological fractures. Data recorded included demographics, injury mechanism, fracture pattern, Injury severity score (ISS), associated injuries, method of fixation, complications and functional outcome. Health related quality of life was assessed using the (EuroQol) and return to sports activities was evaluated using a return to sports questionnaire. The minimum follow up was 24 months (24–39). Results. Out of 60 patients, 53 (29 male) met the inclusion criteria. The mean age was 43 years (21–63), mean ISS was 25.1 (9–58). There was a significant decrease in quality of life (p<0.0001). The decrease was significant in all 5 EQ5D domains with mobility, usual activities and pain to be most significantly affected, p<0.0001. There was also a significant decrease in sporting activities (p>0.0001), (42 patients reported a decrease; 6 patients performed the same degree of activities and 5 reported an increase (they had the lowest mean ISS of 18 points)). Regression analysis showed lower extremity injury to be a significant risk factor for decreased sporting and physical activity, p> 0.049. Conclusion. Pelvic fracture causes a significant decrease in quality of life and return to sports activities. The presence of a lower limb fracture is a significant risk factor for a reduced sporting activity

Objectives. The additive use of an external modular device may improve dorsal compression forces in pelvic external fixation. This would improve the efficiency of indirect reduction and stabilization with an anterior pelvic external fixator. The purpose of this study was to determine the forces of the posterior pelvis achieved by a new device improving the application of a supraacetabular anterior external fixator compared with other constructs. Material and Method. Synthetic pelvic models were used. Complete pelvic ring instability was created by symphyseal and unilateral sacroiliac joint disruption. Four different constructs of fixation were tested. A pressure-sensitive film was placed in the sacroiliac joint. The constructs were applied in a standardized way. The maximum sacroiliacal compression loads (N) of each trial was recorded. Statistics was performed with the student t-test. Results. Standard supraacetabular two-pin external fixator achieved a dorsal compression load of 13.84 (SD 8.13). The new dorsal pelvic compression device delivered 177.05N (SD 32.32) of load across the sacroiliac joint when the pins were inserted half way and 183.58N (SD 46.64) with full pin insertion. Both the half- and full-pin construct demonstrated a significant dorsal load improvement with the pelvic compressor (p<0.05) compared with the standard supraacetabular fixator group. The C-clamp revealed compression forces of 384.88N (SD 22.95), which was significantly greater than all the other groups (p<0.05). Conclusion. We tested a simple and new modular device for improved application of pelvic external fixation. The centres of rotation of supra-acetabular pins were determined and used to achieve greater dorsal compression forces in disrupted pelvic ring injuries. The compression load is less than with a C-Clamp, but significantly greater than the familiar technique of standard external supra-acetabular fixation. This improves the initial stability in acute management of unstable, disrupted and life threatening pelvic ring fractures

Aims

The aim of this study was to investigate the association between fracture displacement and survivorship of the native hip joint without conversion to a total hip arthroplasty (THA), and to determine predictors for conversion to THA in patients treated nonoperatively for acetabular fractures.

Aims

The best method of treating unstable pelvic fractures that involve the obturator ring is still a matter for debate. This study compared three methods of treatment: nonoperative, isolated posterior fixation and combined anteroposterior stabilization.

The purpose of this study was to describe the radiological characteristics of a previously unreported finding: posterior iliac offset at the sacroiliac joint and to assess its association with pelvic instability as measured by initial displacement and early implant loosening or failure. Radiographs from 42 consecutive patients with a mean age of 42 years (18 to 77; 38 men, four women) and mean follow-up of 38 months (3 to 96) with Anteroposterior Compression II injuries, were retrospectively reviewed. Standardised measurements were recorded for the extent of any diastasis of the pubic symphysis, widening of the sacroiliac joint, static vertical ramus offset and a novel measurement (posterior offset of the ilium at the sacroiliac joint identified on axial CT scan). Pelvic fractures with posterior iliac offset exhibited greater levels of initial displacement of the anterior pelvis (anterior sacroiliac widening, pubic symphysis diastasis and static vertical ramus offset, p < 0.001,0.034 and 0.028, respectively). Pelvic fractures with posterior ilium offset also demonstrated higher rates of implant loosening regardless of fixation method (p = 0.05). Posterior offset of the ilium was found to be a reliable and reproducible measurement with substantial inter-observer agreement (kappa = 0.70). Posterior offset of the ilium on axial CT scan is associated with greater levels of initial pelvic displacement and early implant loosening.

Cite this article: Bone Joint J 2014;96-B:1535–9.

The aim of this study was to review the number of patients operated on for traumatic disruption of the pubic symphysis who developed radiological signs of movement of the anterior pelvic metalwork during the first post-operative year, and to determine whether this had clinical implications. A consecutive series of 49 patients undergoing internal fixation of a traumatic diastasis of the pubic symphysis were studied. All underwent anterior fixation of the diastasis, which was frequently combined with posterior pelvic fixation. The fractures were divided into groups using the Young and Burgess classification for pelvic ring fractures. The different combinations of anterior and posterior fixation adopted to stabilise the fractures and the type of movement of the metalwork which was observed were analysed and related to functional outcome during the first post-operative year.

In 15 patients the radiographs showed movement of the anterior metalwork, with broken or mobile screws or plates, and in six there were signs of a recurrent diastasis. In this group, four patients required revision surgery; three with anterior fixation and one with removal of anterior pelvic metalwork; the remaining 11 functioned as well as the rest of the study group.

We conclude that radiological signs of movement in the anterior pelvic metalwork, albeit common, are not in themselves an indication for revision surgery.