Introduction

Haemodynamically compromised patients with biomechanically unstable pelvic fractures need reduction of the pelvic volume to effect tamponade of bleeding bone and vessels. Knee binding, to help achieve this, is advocated in standard Advanced Trauma and Life Support teaching but is rarely used. There are no reports in the literature as to the benefits derived from this simple manoeuvre. The aim of this study was to investigate whether there was an effect on symphysis pubis closure by binding the knees together and to quantify this.

Crescent fractures are represented by a spectrum of morphological fracture patterns, sharing a common mechanism of injury. We propose three distinct types according to the extent of Sacroiliac (SI) joint involvement and the size of the crescent fragment, which enables a pragmatic choice of surgical approach and stabilisation technique.

Crescent fractures are fracture dislocations of the SI joint in which there is variable amount of disruption of the SI ligaments extending proximally as a fracture of the posterior iliac wing. We identified three groups of Crescent fractures according to the extent of SI joint involvement, relationship of the fracture line to the S1 and S2 nerve root foramina on anteroposterior and outlet plain radiograph views, and CT films. Type I involves the less than inferior third of the SI joint with a large posterior iliac fragment left attached to the sacrum. This is best approached anteriorly for stabilisation. Type II has between one-third to two-thirds involvement of the SI joint and is treated according to Helfet's technique. Type III has a very small crescent fragment left attached to the sacrum and the inferior two-thirds of the SI joint is disrupted. This is treated with percutaneous SI screws, but will need anterior open reduction in delayed presentations. Based on this, we treated sixteen patients and followed them for at least two years. There were four Type I, four Type II and eight Type III fractures. Fifteen had anatomical reduction and stabilisation of the SI joint with good functional results. Delayed referral, the presence of significant soft tissue injury posteriorly and infected external fixator pins.

From our experience we would like to propose this functional classification of crescent fractures which we find useful in making a choice of surgical approach and stabilisation technique to achieve satisfactory reduction and stabilisation of sacroiliac joint.

Introduction: Acetabular fractures are increasing in incidence and no previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and recovery. The incidence, outcome and recovery of operatively managed acetabular fractures with associated neural injuries were studied from a three-year cohort of patients.

Methods: This retrospective case series study of 456 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 29 (6.3%) acetabular fractures associated with neural injuries. The fractures were classified using the Letournel system, neural injuries classified as either complete or incomplete and the degree of post-operative skeletal displacement quantified using radiographs. A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: Overall, the cohort had a mean age of 34 years, 17 (59%) were male and the mean delay from time of injury to time of acetabular surgery was 16 days (range 4 – 53 days). All fractures involved posterior wall and/or posterior column and 23 (79%) were of the more complex, associated type, Letournel fracture patterns. Full resolution of neural symptoms was observed in 9 (31%) patients with a mean fracture reduction of 1.6mm. Partial neurological improvement was observed in 15 patients. Ongoing complete nerve palsy was observed in 5 patients, associated with a mean fracture reduction of 2.5 mm and a significantly longer delay to surgery of 32 days (p< 0.05).

Discussion: Acetabular fractures involving the posterior wall or column have a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, affords a good neural outcome for these patients. In similiar injuries with complete nerve palsy, delayed and sub-optimal surgical reduction predicts a poor prognosis.

Introduction: The incidence, outcome and recovery of operatively managed pelvic ring fractures were studied from a three-year cohort of patients. No previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and natural recovery in these potentially devastating injuries.

Methods: This retrospective case series study of 489 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 42 (8.6%) patients who had sustained pelvic ring injuries with associated neural injuries. Each pelvic injury was classified using the Tile and Burgess & Young classifications, neural injuries were classified as either complete or incomplete and the degree of post-operative skeletal displacement was quantified using radiographs. A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: The mean age of patients with neural injuries was 28 years, 32 (76%) were male and 37 (88%) had unstable, Tile type C, fracture patterns. The mean delay from time of injury to time of pelvic surgery was 11 days (range 3 – 42 days). Full resolution of neural symptoms was observed in 16 (38%) patients, with a mean fracture reduction of < 6mm. Incomplete improvement was observed in 11 patients and 15 patients had ongoing complete lumbosacral palsy. Patients who failed to achieve full resolution of neural function had a mean fracture or sacro-iliac joint reduction of 8.8 mm and the mean delay to surgery was 24 days.

Discussion: Pelvic ring injuries with an unstable fracture pattern are associated with a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, creates a better environment to achieve a good neural outcome. In such injuries with complete nerve palsy, delayed and suboptimal surgical reduction predicts a poor prognosis.

Introduction: Acetabular fractures are increasing in incidence and no previous published studies have reviewed the factors influencing the outcome of operative stabilization on the neural function and recovery. The incidence, outcome and recovery of operatively managed acetabular fractures with associated neural injuries were studied from a three-year cohort of patients.

Methods: This retrospective case series study of 456 referrals to a tertiary referral unit, from 1st Jan 2004 to 31st Dec 2006, identified 29 (6.3%) acetabular fractures associated with neural injuries.

The fractures were classified using the Letournel system, neural injuries classified as either complete or incomplete and the degree of post-operative skeletal displacement quantified using radiographs.

A mean clinical and radiographic follow up of 3.5 years was achieved and statistical analysis was performed used chi-squared (SPSS)

Results: Overall, the cohort had a mean age of 34 years, 17 (59%) were male and the mean delay from time of injury to time of acetabular surgery was 16 days (range 4 – 53 days).

All fractures involved posterior wall and/or posterior column and 23 (79%) were of the more complex, associated type, Letournel fracture patterns.

Full resolution of neural symptoms was observed in 9 (31%) patients with a mean fracture reduction of 1.6mm. Partial neurological improvement was observed in 15 patients.

Ongoing complete nerve palsy was observed in 5 patients, associated with a mean fracture reduction of 2.5 mm and a significantly longer delay to surgery of 32 days (p< 0.05).

Discussion: Acetabular fractures involving the posterior wall or column have a high incidence of neural injury. Accurate fracture reduction and stabilization, achieved without a prolonged delay, affords a good neural outcome for these patients. In similiar injuries with complete nerve palsy, delayed and sub-optimal surgical reduction predicts a poor prognosis.

We report the outcome of 161 of 257 surgically fixed acetabular fractures. The operations were undertaken between 1989 and 1998 and the patients were followed for a minimum of ten years. Anthropometric data, fracture pattern, time to surgery, associated injuries, surgical approach, complications and outcome were recorded. Modified Merle D’Aubigné score and Matta radiological scoring systems were used as outcome measures. We observed simple fractures in 108 patients (42%) and associated fractures in 149 (58%).

The result was excellent in 75 patients (47%), good in 41 (25%), fair in 12 (7%) and poor in 33 (20%). Poor prognostic factors included increasing age, delay to surgery, quality of reduction and some fracture patterns. Complications were common in the medium- to long-term and functional outcome was variable. The gold-standard treatment for displaced acetabular fractures remains open reduction and internal fixation performed in dedicated units by specialist surgeons as soon as possible.

The incidence of acetabular fractures within the UK is about 3 in 100,000 of the population per year. Since Letournel and Judet first proposed that operative reduction and rigid internal fixation of displaced fractures will likely lead to better outcome, operative management of such fractures has become standard management in major trauma centres. Long term outcome results following acetabular surgery have been reported sparingly.

Two hundred and fifty-seven displaced acetabular fractures underwent an open reduction and internal fixation at St. George’s Pelvic Unit between 1992 and 1997. All surgery was performed by a single surgeon. 161 patients were followed up prospectively for a minimum of 10 years. Those lost to follow up were excluded. Anthropometric data, fracture pattern, time to surgery, associated injuries, approach, complication and outcome recorded on a database. Modified Merle D’ Auberge score was utilized as outcome measures.

The mean age was 36 years (15 to 85). Road traffic accident was the commonest mechanism of injury. We observed simple fractures in 34 % and associated fractures in 66%. 52% suffered polytrauma. Average time to surgery was 11 days and anatomic reduction was achieved in 73.9%. Results were excellent 46.8 %, good 25.5 %, fair 7.5 %, and poor 19.2 %. Poor prognostic factors were increasing age, delayed surgery, poor reduction, and posterior column, transverse posterior wall and T-shaped fracture patterns.

Acetabular surgery poses a major challenge to the trauma surgeon. Complications in the immediate, mid and long term are not rare. Our results compare to other series with shorter follow-up. We believe that the gold standard treatment for displaced acetabular fractures must be open reduction internal fixation performed by a dedicated pelvic surgeon at the earliest time possible. Moreover whether we are merely postponing the inevitable post-traumatic arthritis is still unknown.

Purpose: The authors would like to report the outcome following evaluation of surgical treatment for acetabular fractures with more than 10 years follow-up.

Materials and methods: 133 consecutive patients were evaluated with 10–16 years post surgery follow-up (mean 12 years). Mean age was 34 years (17 to 70 range) and male: female were 2:1. 90% of our cases were tertiary referrals. The follow-up assessments included AP pelvis and Judet view radiographs and clinical evaluation was performed with the Harris hip score, Modified Merle d’Aubigne score and the SF 36v2 health survey.

Results: Fracture reduction was anatomical in 69% of the patients and in 31% it was non-anatomical. The reduction of the acetabular fractures was considered anatomical when all five lines on post-operative radiographs were corrected and the hip was congruent. Among our patients, 19% had excellent clinical results according to the modified Merle d’Aubigne Score and 58% according to the Harris Hip Score. A poor clinical outcome was identified in 18% of our patients according to the modified Merle d’Aubigne Score and 23% according to the Harris Hip Score. Radiographic evidence of osteoarthritis was in 35,8% of our patients (all grades of arthritis). 6 of our patients had neurological complications (sciatic nerve palsy) (3 pre-operatively, 2 post- operatively and in one patient there was a delayed sciatic nerve palsy secondary to haematoma). In 7 patients (8.6%) there was heterotopic ossification but in only three that was clinically a problem. Two patients developed intraoperatively pulmonary embolism. We had no post-operative deep vein thrombosis or pulmonary embolism.

Conclusions: Our results compare favourably with those of previous published studies with shorter follow-up period. Anatomical fracture reduction is mandatory and improves the clinical outcome. Infection and avascular necrosis are associated with poor clinical outcome. Early surgical intervention for displaced acetabular fractures can improve the final outcome.

Specific radiological features identified by Brandser and Marsh were selected for the analysis of acetabular fractures according to the classification of Letournel and Judet. The method employs a binary approach that requires the observer to allocate each radiological feature to one of two groups. The inter- and intra-observer variances were assessed. The presence of articular displacement, marginal impaction, incongruity, intra-articular fragments and osteochondral injuries to the femoral head were analysed by a similar method. These factors were termed ‘modifiers’ and are generally considered when planning operative intervention and, critically, they may influence prognosis.

Six observers independently assessed 30 sets of plain radiographs and CT scans on two separate occasions, 12 weeks apart. They were asked to determine the presence or absence of specific radiological features. This simple binary approach to classification yields an inter- and intra-observer agreement which ranges from moderate to near-perfect (κ = 0.49 to 0.88 and κ = 0.57 to 0.88, respectively). A similar approach to the modifiers yields only slight to fair inter-observer agreement (κ = 0.20 to 0.34) and slight to moderate intra-observer agreement (κ = 0 to 0.55).

There are unacceptable delays in the management of pelvic trauma in the United Kingdom. In 2003 this became a political issue after TV and radio coverage. Changes to the service were introduced, including trauma coordinators and a special tariff, but has it made a difference?

We describe two patients aged 16 and 25 years with osteogenesis imperfecta who sustained displaced fractures of the acetabulum following minor trauma. The femoral heads were deformed by impact against the acetabular margin and both cases underwent surgical reconstruction. The quality of the bone and soft tissues made the operations challenging. There were potential complications specific to osteogenesis imperfecta, including bleeding, the creation of secondary fracture lines and shredding of the soft-tissue. The cases provide useful guidelines for addressing these difficulties.

Aims: To study the natural history and treatment of chronic skeletal pelvic pain following childbirth. Methods: 53 patients were studied, of which 13 had surgery to the symphysis pubis (11 fusion, 2 stabilisation). A detailed history was recorded and an examination carried out. Investigations included pelvic X-rays with stress views and MRI of the symphysis pubis in a selected group. Results: Mean age at onset 30.6 years, gestation 39.3 weeks (36–42). 16 of the 17 subsequent pregnancies were associated with recurrence of symptoms. Long term disability showed no relation to type of delivery (p> 0.5). Pain was worse before menstruation. 55% of patients beneþted from conservative management. This did not relate to the site of pain (p> 0.1). Stress views of the symphysis: 39, mean vertical shift 2.2mm. There was no correlation between shift and symptoms. MRI of the symphysis:17, 6 were normal and 11 revealed non-speciþc changes. Surgery:mean age at surgery 34.8 y, time to operation 4.2 y and follow up 23.6 m. Outcome: 7 good, 6 no beneþt. There was a strong reverse correlation between disability and outcome (r=−0.84) while the site of pain had no effect on outcome (p> 0.8). Conclusions: Chronic skeletal pelvic pain following pregnancy is poorly understood and under-diagnosed. It tends to be recurrent and its onset is related to hormonal and mechanical factors in pregnancy. The type of delivery is unlikely to be important although care should be taken with leg and patient positioning. There is no relationship between shift and severity. Conservative treatment is the main standby. Surgery, on the basis of this small study, is useful in those with moderate disability but contraindicated in those with severe disability.

We have prospectively compared the fixation of 100 intertrochanteric fractures of the proximal femur in elderly patients with random use of either a Dynamic Hip Screw (DHS) or a new intramedullary device, the Gamma nail. We found no difference in operating time, blood loss, wound complications, stay in hospital, place of eventual discharge, or the patients' mobility at final review. There was no difference in failure of proximal fixation: cut-out occurred in three cases with the DHS, and twice with the Gamma nail. However, in four cases fracture of the femur occurred close to the Gamma nail, requiring further major surgery. In the absence of these complications, union was seen by six months in both groups.

We aimed to develop a better understanding and method of rating the success or failure of low back surgery by studying 185 patients prospectively. Identical pre-operative and postoperative assessment by an independent observer included pain, disability, physical impairment, psychological distress and illness behaviour. Outcome was assessed by the patient, by the observer and by return to work. There was 96% follow-up at two years. Correlation co-efficients varied considerably between the various measures of outcome, both patient and observer appearing to base their assessment mainly on postoperative status rather than on any change produced by surgery. The observer was influenced most by postoperative pain, disability and physical impairment. Patients were influenced most by residual physical impairment, type of surgery and proportional change in disability. Return to work was moderately influenced by postoperative disability and to a larger extent by social and work-related factors. We developed a simple formula to judge overall success or failure which accurately reproduced the combined assessment of patient and observer. If surgical audit is to be meaningful it must be based on an improved understanding of how the outcome of surgery should be assessed.