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Pelvic Ring Injuries Definitive Treatment

Steven A. Olson, MDRafael Neiman, MD

Created March 2004Revised 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


• Associated injuries are common and treatment must be coordinated with other teams– Trauma Surgery– Urology– Neurosurgery

• Combined injuries may require exploratory laparotomy


• 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


• 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 ManagementFractures 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



– 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)


• 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


• Bucholz type III



• 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

• 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

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

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

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

from Matta JM, Saucedo T: Clin Orthop 242:83, 1989; original by Zilbert

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

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

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.

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