Introduction: L5/S1 injuries can be associated with pelvic fracture but unfortunately they are often missed. Left untreated these patients may suffer disabling lower back pain. Our goal is to study the frequency of these injuries in pelvic fractures treated at this institution, thereupon to determine how many are missed and the outcome if this injury is treated conservatively. We will describe the radiological findings, anatomical features and possible surgical treatments.

Materials and Methods: A retrospective analysis was undertaken of pelvic fractures treated at this institution from 2000 onward. Outcome scores were taken from the patient records. All CT scans and x-rays were scru-tinised for a Lumbosacral Junction Injury(LJI). Numbers missed were tallied against numbers diagnosed and treated. Patient outcome measures were compared using the Matta Hip Scores. It was noted whether low back or hip pain contributed to their symptoms most.

Results: The incidence of lumbar sacral injuries associated with vertical shear pelvic fractures was 20%. Of these, 75% had not been identified as a specific lumbar-sacral injury. The remaining 25% which were identified and treated with fixation of the lumbar sacral junction had an excellent result. We have identified specific morphology patterns and propose a CT based grading system.

Discussion: We suggest that a heightened level of awareness is needed for these important injuries in pelvic trauma as their occurrence changes the management. The incidence appears to be higher than that reported by Isler and suggest our CT based classification be used to grade these injuries.

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.

INTRODUCTION: Unstable distal and proximal tibial fractures that are not suitable for intramedullary nailing are often treated by open reduction and internal fixation (ORIF) and/or external fixation techniques. Discuss the treatment of these injuries with Percutaneous Plating technique which offers advantages over standard external fixation and/or ORIF as it minimises soft tissue trauma and does not disturb the osteogenic fracture haematoma.

PURPOSE: We report on the experience using percutaneous plating of unstable distal fractures in a district General Hospital setting and discuss the technique used and the applicability of this method to military personnel with high functional demands.

METHOD: a retrospective review of all patients treated with percutaneous plating technique for an unstable distal tibial fracture between 1998 and 2001 was undertaken. Fractures were classified to the AO system Reudi and Allgower. Indications for use of the percutaneous plate technique were distal tibial fractures which were initially managed in plaster until definitive fixation. No external fixation was used. The operation consisted of supine position on a radiolucent table. The fracture was reduced by closed methods and a DCP was shaped to fit the tibia. This was then positioned on the medial tibia in an extraperiosteal, subcutaneous tunnel. 4.5mm screws were fitted via stab incisions as appropriate to hold the plate in position. No splinting was used other than the plaster itself unless the patient was felt to be unable to comply with a touch weight bearing regime. Clinical and radiological follow up was 6–8 weeks, 3 months and 6 months post injury.

RESULT: 22 patients were identified, 20 of whom were available to follow up. Mean age was 38.3 years (range 17–71). There were 18 males and 4 females. Mechanism of injury was a fall in 12, motorcycle RTA in 6, and rugby/ football injury in 4. Most fractures were 42-A1/42-B1. 4 fractures had distal intra-articular fracture extensions. All were closed injuries. Over 50% of patients underwent fixation within 24 hours of the injury. Mean hospital stay was 6.5 days (2–31). There were no deep infections (one superficial infection which resolved with oral antibiotic treatment). Most patients achieved callus by 8 weeks, all by 3 months. Mean time to full weight bearing was 12 weeks (8–17). By 6 months only 2 fractures had not united. These united at 7 months. There were no non-unions and only one mal-union. There were no cases of failure of fixation.