Pelvic Ring Injuries Definitive Treatment Steven A. Olson, MD Rafael Neiman, MD Created March 2004 Revised 2007

Introduction Evaluation and Classification of Pelvic Ring Injuries (PRI) Acute Management of PRI Definitive Management of PRI

Introduction Definitive Treatment of PRI Defining instability The decision to operate Preoperative planning Selection of approach Techniques of reduction and fixation Biomechanics of fixation techniques Outcomes in PRI

Instability As with any musculoskeletal articulation, stability relies on three factors, to variable degrees: Bony Stability Soft Tissue Stability Capsulo-ligamentous structures Dynamic Stability Muscular structures-minimal contributor

Instability Bony and soft tissue stability The 3 bones of the pelvic ring have no inherent stability. Alone they cannot support the axial or appendicular skeleton However, the sacrum is the ‘keystone’ to the bony stability of the pelvic ring when ligamentous attachments are intact. Interosseous Sacroiliac ligaments are most important for posterior stability

Instability Multiple opinions exist for defining pelvic ring instability Some use radiographic displacement, in combination with physical exam, to define instability Most surgeons generally define it as the inability to sustain loads required for patient mobilization without significant displacement or deformation

Instability Multiple opinions exist for defining pelvic ring instability Several classification systems address pelvic ring injuries, some with focus on instability, others with focus on injury pattern: Tile Bucholz AO/OTA Young and Burgess Letournel

Instability Refer to section on Classification for details For purposes of simplicity in defining treatment options, the Bucholz classification will be used Type I-Anterior injury with minimal posterior involvement Type II-rotationally unstable, vertically stable Type III-rotationally and vertically unstable

Preoperative Planning A pelvic C-clamp/external fixator may be in place due to prior hemodynamic instability (refer to section on ‘acute management of pelvic ring injuries’). This will need removal for definitive treatment, often 5-7 days post-injury

Preoperative Planning Associated injuries are common and treatment must be coordinated with other teams Trauma Surgery Urology Neurosurgery Combined injuries may require exploratory laparotomy

Preoperative Planning When an exploratory laparotomy is performed, this often gives the orthopaedist opportunity to stabilize the anterior pelvic ring These opportunities should be used, as the trauma patient may occasionally be unable to withstand future operations

Preoperative Planning Timing is important within 24-48 hours, the fracture-dislocations are most mobile and may allow the best reduction with closed techniques Routt has shown success with very early stabilization (at zero days post injury) with closed reduction and percutaneous pinning

The Decision to Operate-Indications Most PRI fall into Bucholz type I injury Anterior disruption of the pelvic ring with nondisplaced fracture of the sacrum or slight tearing of the anterior SI ligament. These are inherently stable Bruce D. Browner, MDJ. Dean Cole, MD, Initial management of pelvic ring disruption. Instructional Course Lectures 1988, Volume 37:129

Non-Operative Management Fractures amenable to non-operative treatment include: Lateral impaction type injuries with minimal (< 1.5 cm) displacement Pubic rami fractures with no posterior displacement Gapping of pubic symphysis < 2.5 cm Operative treatment indicated rarely for symptomatic delayed union or nonunion

Non-Operative Treatment Bucholz type I injuries can be managed with bed to chair mobilization and weight bearing as tolerated. Weight bearing typically requires support with a walker or crutches initially. Serial radiographs are required after mobilization has begun to monitor for subsequent displacement. If displacement of the posterior ring > 1cm is noted weight bearing should be stopped. Operative displacement could be considered for gross displacement.

The Decision to Operate -Indications Bucholz type II Anterior pelvic ring injury and complete tearing or avulsion of the anterior SI ligament complex with sparing of the posterosuperior SI ligament complex Bruce D. Browner, MDJ. Dean Cole, MD, Initial management of pelvic ring disruption. Instructional Course Lectures 1988, Volume 37:129

The Decision to Operate -Indications Rotationally unstable injuries (typically external rotation injuries) Larger displacements anteriorly suggest further instability posteriorly These need operative fixation when gapped open > 2 - 2.5 cm

Techniques Bucholz II Anterior fixation options (anterior ring) external fixation (simple anterior frame constructs) internal symphyseal plating (single or double) ramus fixation

Techniques Symphyseal plating-incisions Pfannenstiel if no incision has been made good visualization good cosmesis Avoid detaching rectus (although one side may be torn at time of injury) Use prior midline or paramedian approaches if available

Techniques Symphyseal Plating Reduction for rotational displacement Expose the lateral portion of the pubic tubercles Use a Weber reduction clamp; avoid clamping through the foramen Matta and Tornetta, CORR 329, pp129-140, 1996

Techniques Choice of anterior plating technique Controversies exist single plate 2 or 4 hole symphysis plate superiorly (6.5 mm screws) 6 hole plate anteriorly (3.5 or 4.5 mm screws) dual plate combination of above, placed at right angles

Techniques Choice of plating technique-how to decide? Single plate for open book injuries when stable posteriorly or posterior fixation is planned Tile recommends that dual plating should be reserved for the unusual situation where the posterior injury cannot be addressed due to physiologic instability; the anterior construct can then better withstand superior-inferior and anterior-posterior forces A single plate and external fixation is also appropriate

Techniques When single anterior plating has failed, it can be from patient compliance, but may more likely be related to unrecognized or underestimated posterior injuries (Matta, Olson, Bucholz)

Techniques Pubic Ramus Fractures ORIF if distracted over 1-1.5 cm Or significantly rotated to impinge on vaginal vault, bladder, or rectum (‘tilt fracture’)

Techniques Pubic Ramus Fractures Rarely repaired in Bucholz type II fractures Matta series-over 84 percent treated nonoperatively, even in unstable injuries treated posteriorly (Bucholz III or Tile C)

The Decision to Operate -Indications Bucholz type III Complete disruption posteriorly, to include SI joint dislocation Sacral fracture SI joint fracture dislocation (‘crescent fracture’) Variable anterior injury symphysis disruption ramus fractures

The Decision to Operate -Indications Bucholz type III Bruce D. Browner, MDJ. Dean Cole, MD, Initial management of pelvic ring disruption. Instructional Course Lectures 1988, Volume 37:129

The Decision to Operate -Indications Bucholz type III These result in a multiplanar displacement of the hemipelvis Translation-posterior & superior Rotation-external & flexion These injuries are completely unstable and require operative reduction and fixation; often they cannot be reduced by closed means due to interposing SI joint ligaments and capsule

Selection of Approach Which portion of the PRI should be approached first? If rami fractured, repair posterior ring first anterior fixation only if rami fractures meet criteria If symphysis disrupted, may plate anterior ring first but must be anatomical (posterior reduction and fixation 1st may be more reliable)

Selection of Approach How should the posterior ring injury be approached? Anterior (supine) Posterior (prone) Percutaneously Combinations of above External fixation is not definitive

Selection of Approach How should the posterior ring injury be approached? other injuries may dictate the positioning of the patient severe pulmonary/thoracic trauma unstable spine trauma severe soft tissue injuries (abrasion/contusion) associated degloving (I.e. Morel-Lavalle)

Selection of Approach Supine position-Anterior Approach Indications SI joint dislocation SI joint fracture-dislocation (crescent) Iliac wing fracture Contraindications Sacral Fracture Comminution/impaction of sacral ala results in poor screw fixation

Techniques Anterior fixation of the SI joint dislocation Advantages good visualization good stability soft tissue complications less common Disadvantages more difficult approach L5 nerve root at risk

Techniques Supine position-Anterior Approach Fixation involves anterior plating, using recon-type plates or dynamic compression plates placed at 90° to each other (at least three hole plate with one screw into the sacrum) M Tile in Schatzker, Tile (eds). Rationale of Operative Fracture Care, Springer, Berlin, 1996, p221-270

Techniques Anterior fixation of the SI joint dislocation Incision along iliac crest to beyond ASIS Essentially the lateral window of the ilioinguinal approach Sweep away iliacus to approach SI joint Can be used in conjunction with acetabular ORIF

Selection of Approach Prone position-Posterior approach Indications SI joint dislocation SI joint fracture dislocation (crescent) Sacral fracture Contraindications Soft tissue problems Patient unable to tolerate prone position

Techniques Prone position-Posterior approach Advantages Disadvantages good visualization and stability versatile uncomplicated approach Use of clamps for fracture reduction Disadvantages soft tissue injuries may be present and can occur

Techniques Prone position-Posterior approach Vertical incision 1cm lateral to the posterior iliac spine, from the crest to the sciatic notch The G. maximus is incised and reflected anterolaterally, allowing visualization to the sciatic notch A laminar spreader can be placed within the fracture to clear debris (Borrelli, Koval, and Helfet) if extraforaminal

Matta, Surgical Approaches to the Acetabulum

Matta, Surgical Approaches to the Acetabulum

Techniques Posterior reduction techniques (Matta and Tornetta) A pointed reduction clamp is placed with one point on the anterior sacral ala lateral to the S1 foramen and the other placed on the outer ilium. A Weber clamp can be used for cephalad displacement

Matta and Tornetta, CORR 329, pp129-140, 1996

Techniques Reduction of the posterior ring injury can be aided by initial reduction and plating of the anterior ring injury (if anterior injury is a symphysis disruption) Reduction for rotational and vertical displacement an anchoring plate with a Jungbluth (AO) reduction clamp can be effective for anterior reductions prior to symphyseal plating

Matta and Tornetta, CORR 329, pp129-140, 1996

Techniques Prone position-Posterior approach Options for fixation SI screws for SI joint fractures/dislocations Transiliac plates or rods

Techniques Posterior fixation Posterior plating or transiliac rods can be placed these require a second approach on the contralateral side

Techniques Posterior fixation Single or multiple iliosacral screws can be placed (2 preferred with threads into S1 superior portion) An anatomic ‘safe zone’ has been established

Techniques - Sacral Fixation Between the S1 foramen and the superior margin of the ala on the 40 degree cephalic (outlet) view Between the neural canal and the anterior margin of the body on the 40 degree caudad (inlet) view from Matta JM, Saucedo T: Clin Orthop 242:83, 1989; original by Zilbert

Techniques Percutaneous Techniques of iliosacral screw fixation Can be done with patient either supine or prone Less soft tissue dissection, less risk of infection Must have an acceptable closed reduction in order to be successful Often Bucholz III cannot be reduced by closed means

Complication of Injury Pain Deformity Soft-tissue degloving lesions Neurologic injury Impotence

Complications of Treatment Infection Neurologic Injury Loss of reduction

Prevention of Complications Recognize soft-tissue injury Avoid incisions through compromised tissue Use appropriate fixation for the injury Use care when placing implants

Closed Internal Degloving Injury Traumatic separation - subcutaneous tissue from fascia Fluid cavity develops with hematoma and necrotic fat Degloving over trochanter is known as “Morel-Lavelle’ Lesion” Diagnosis Made On Physical Exam: Soft Fluctuant Area Over The Lesion Positive Fluid Wave Loss of Local Cutaneous Sensation

Pre-operative Considerations Thorough surgical debridement of degloving injury prior to or at time of fixation via surgical approach or via separate incision Plan separate incisions carefully to avoid limiting surgical access Leave skin and subcutaneous tissue open May use delayed primary closure in some cases

Infection Serous drainage is common for several days post-operatively Bloody drainage or purulence is not normal. Consider returning to OR for I&D when signs of recurrent or abnormal drainage occur. Antibiotic therapy should be guided by cultures

Several structures can be at risk during surgical fixation Hardware Placement Take Care To Avoid Injury to Neurovascular Structures Several structures can be at risk during surgical fixation L5/S1 nerve roots, sacral canal, branches of the internal iliac system.

Biomechanics Use fixation appropriate to the injury Several investigators have compared the previously discussed fixation options for structural rigidity Few outcome studies have been performed to directly compare methods, so much of the information is based on laboratory benchtop studies

Biomechanics Anterior fixation methods External Fixation Symphysis/Ramus plating Symphysis plating provides superior rigidity to internal and external rotation forces Neither provides sufficient rigidity for vertical instability/posterior injuries

Biomechanics Posterior fixation methods Multiple studies have compared various posterior stabilization procedures Simonian found no significant difference for single screw, double screw, plate, or transiliac bar with regards to load to failure in double limb stance models

Biomechanics Posterior fixation Olson compared displacements following Bucholz III injuries in single limb, muscle- stabilized model single SI screw multiple SI screws SI plate Transiliac plates and rods All constructs were stiffer than a single screw

Biomechanics The most secure form of fixation may be two sacroiliac screws -or- two anterior plates with an SI screw For bilateral dislocations (‘grade IV’) the above construct may be insufficient a single plate or bar in addition to a single SI screw on each side may be most secure

Outcomes Functional outcomes are often assessed The most common outcome is residual pain The most significant influence on outcome in PRI was neurologic injury

Outcomes Multiple studies have compared outcomes in varying injuries Comparison of Tile A, B, and C or Injury Severity Score (ISS) show no significant difference in outcome in some studies Similarly, fracture location did not significantly affect outcome in every study

Outcomes Often patients do not return to previous levels of employment or activity (return: 40% Cole et al, 75% Miranda et al, 67-83% Tornetta) Erectile dysfunction occurs in 20-80%

Outcomes Promising outcomes come from those with Bucholz II injuries who undergo ORIF and achieve a more anatomical reduction Tornetta (1996) reports 96% have full ambulation 69% have no residual pain 83% were able to resume their previous job 0% had difficulty with sexual activity

Summary of Treatment Bucholz I - Nonoperative Bucholz II - Operative treatment with anterior or posterior ring stabilization Bucholz III - Operative treatment with posterior and possibly anterior ring fixation

Acknowledgment Pelvic Ring Injuries can be devastating, but with prompt and thoughtful care, outcomes have been shown to improve. Return to Pelvis Index E-mail OTA about Questions/Comments If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org