Basic principles of treatment of breaks of lower extremity and pelvis.

Basic principles of treatment of breaks of lower extremity and pelvis. Reader: Kostiv S. Ya.

Tibia Fractures, Open • When an individual presents with an open tibial fracture, the physician strives to save the life of the patient and the limb, to unite the fracture, and to prevent infection. Maintaining a functional limb is the goal; when that is not possible, the physician must consider amputation.

Frequency • Behrens et al reported an incidence of 2 open tibia fractures per 1000 injuries per year in a defined population group in an industrialized western society; this is 0.2% of all injuries (Behrens, 1982; Behrens, 1986). The incidence and severity may be even higher in the developing worl

Etiology • Motor vehicle accidents, skiing accidents, and high-energy falls are the common causes. The mechanism of injury determines the fracture configuration (eg, skiing injuries typically cause spiral fractures). Most fractures are comminuted. Pedestrians who are hit in the upper and middle one third of the tibia sustain bumper injuries. Distal tibial and plafond fractures are commonly a result of a fall from a significant height.

Presentation • All persons who have undergone high-energy trauma should be examined in accordance with the principles defined by the Road Trauma Committee of the Royal Australasian College of Surgeons/Emergency Management of Severe Trauma (Geller, 1997; Shuler, 1996). The primary survey includes the ABCs (ie, airway, breathing, circulation). A Glasgow Coma Scale score indicates the severity of any head injury component. The secondary survey should include the chest, abdomen, and pelvis for associated injuries, as well as the upper limbs and the contralateral lower limb. The ipsilateral limb also may have other fractures, such as a femur fracture, leading to a floating knee, or joint injuries such as knee dislocations.

Classification • Table Type Wound Description Other Criteria • I <1 cm (so-called puncture wounds) • II 1-10 cm • IIIA >10 cm, coverage available Segmental fractures, farm injuries, • or any injury occurring in a highly contaminated environment • High-velocity gunshot injuries • IIIB 10 cm, requiring soft tissue coverage procedure Periosteal stripping • IIIC With vascular injury requiring repair • Type Wound Description Other Criteria • I <1 cm (so-called puncture wounds) • II 1-10 cm • IIIA >10 cm, coverage available Segmental fractures, farm injuries, • or any injury occurring in a highly contaminated environment • High-velocity gunshot injuries • IIIB 10 cm, requiring soft tissue coverage procedure Periosteal stripping • IIIC With vascular injury requiring repair

Gustilo-Anderson Classification of Open Fractures

Tscherne Classification of Soft Tissue Injuries

Indications • The various limb salvage scoring systems, such as the MESS (Mangled Extremity Severity Score), are good indicators for salvage but poor indicators for amputation; thus, a limb with a good MESS usually should be salvaged, but a limb with a poor MESS does not necessarily require amputation. • Regarding nailing versus external fixation, Bhandari et al reported from a meta-analysis that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in persons with open tibial fractures (Bhandari, 2001; Bhandari, 2000). They also found a reduced risk of reoperation with using reamed nails compared with unreamed nails. This appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail. Plate fixation was found to be uniformly the worst of all methods of internal fixation. Although it may be tempting to use plate fixation for a fracture that is exposed (ie, because of the open nature of injury), the risk of nonunion, malunion, and deep infection is too high to justify the action (Bhandari, 2001).

Contraindications • Absolute contraindications to limb salvage are a completely mangled limb, the presence of warm ischemia for longer than 6 hours, and poor facilities for salvage. • Absolute contraindications to nailing an open fracture are untreated compartment syndrome and types IIIB and IIIC open fractures.

Medical Therapy • ntravenous antibiotics are administered promptly. First-generation cephalosporins (gram-positive coverage) such as cephalothin (1-2 g q6-8h) suffice for Gustilo-Anderson type I fractures. An aminoglycoside (gram-negative coverage) such as gentamycin (120 mg q12h; 240 mg/d) is added for types II and III injuries. Additionally, metronidazole (500 mg q12h) or penicillin (1.2 g q6h) can be added for coverage against anaerobes. Tetanus prophylaxis should be instituted. Antibiotics generally are continued for 72 hours following wound closure. • After initial assessment, the wound is irrigated in the emergency department. A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room as soon as feasible. Debridement within 6 hours is necessary to keep the rate of infection low (Kindsfater, 1995). A key factor in infection prevention is early, rigid stabilization of the fracture.

Surgical Therapy • Fracture repair • Amputation

Complications • Open tibial fractures have higher rates of nonunion, infection, and CPS. • Osteomyelitis may occur and can be acute, subacute, or chronic. It may surface many months or years after injury. • Pin site infections are common with external fixator treatment. Chronic osteomyelitis in the pin sites is relatively common.

Femoral Neck Stress and Insufficiency Fractures

Introduction • Femoral neck stress fractures are a common cause of hip pain in select populations. Chronic, repetitive activity that is common to runners and military recruits predisposes these populations to femoral neck stress fractures. These injuries must be differentiated from insufficiency fractures, which, although similar in appearance and presentation, result from an entirely different pathophysiology and occur in a different population.

Problem • The femoral neck area is subjected to large compressive and sheer forces associated with ambulation. Even in the most sedentary individual, the daily cyclic loading of the hip and femoral neck produces high stresses on the bony trabeculae in this anatomic region. In long-distance runners and other high-performance athletes, the forces across the femoral neck are multiplied exponentially because the athletes' training regimens place tremendous physical burdens on this relatively small bridge of bone, which connects the femoral head to the diaphysis.

Frequency • Femoral neck stress fractures occur most commonly in 2 subsets of the population. Elite distance runners, military recruits, and dancers constitute the first group. The true prevalence of fractures in this group is difficult to pinpoint because such patients with hip pain and femoral neck stress fractures who never present to a physician and whose fractures go on to heal spontaneously are never identified. Data from several military hip fracture studies by Stoneham and Morgan, in Britain, and Volpin and colleagues, in Israel, place the prevalence at 0.2-4.7% in patients without a history of a single traumatic episode.3, 4 The prevalence of stress fractures in the general population may be surmised to be far less than that demonstrated in these 2 groups. • The second group comprises hypoestrogenic (postmenopausal) women and individuals with pathologic entities resulting in osteopenia (eg, osteoporosis, Paget disease, hyperparathyroidism). Fractures in this group are termed insufficiency fractures, because bone quality is insufficient to support the diurnal physiologic demands placed on it.

Etiology • Femoral neck stress fractures in young, otherwise healthy individuals are related to the inability of bony trabeculae weakened by osteoporosis to withstand physical stresses. Unusually high physical demands on normal bone over the long term can lead to mechanical failure of the bone trabeculae. The phenomenon is seen with exercise beyond the point of muscle fatigue, alterations of ground reactive forces that yield abnormal stress patterns in bone, and increased muscular contractions. Contrast this with insufficiency fractures of the femoral neck, which are the result of normal stresses of everyday activity placed on structurally compromised bone. Thus, insufficiency fractures occur in individuals who have concomitant metabolic derangements, such as hyperparathyroidism and renal failure, or menopause. • At least 1 example of a crossover group exists: amenorrheic female athletes. Due to their lack of body fat, female distance runners often temporarily halt their menstrual cycle. As a result, they become hypoestrogenic and, therefore, physiologically similar to postmenopausal females.

Pathophysiology • A closer look at the genesis of a stress fracture in the femoral neck reveals that the damage manifested on the physical level derives not from a traumatic event per se but rather from a metabolic derangement. Bone initially responds to increased mechanical loading by increasing resorption. Resorption is normally counterbalanced by an equal but opposite, osteoblast-mediated metabolic repair. Under situations of extraordinarily high levels of training, such as those faced by military personnel and elite athletes, bone resorption begins to exceed the bone's capacity to remodel. Additionally, pharmacologic (glucocorticoids), nutritional (vitamin D and calcium deficiency), and other (postmenopausal, hyperparathyroid) states can adversely affect osteoblasts' ability to keep pace with osteoclastic resorption. If this metabolic imbalance persists, microfractures develop that eventually weaken bone to the point of a complete fracture.

Presentation and examination • Although femoral neck stress fractures are relatively uncommon in the general population, they must be part of any thorough physician's differential diagnosis for an athlete presenting with anterior hip or groin pain. A history of insidious hip or groin pain that is directly related to an increase in the level or duration of athletic activity and that is relieved by rest is typical. Early diagnosis is often difficult because of the lack of an identifiable traumatic event, which tends to dissuade primary care physicians from obtaining radiographs. Even the astute physician ordering hip films upon first presentation may overlook this diagnosis because fracture callus is not evident early in the process. A bone scan may be helpful in cases in which suspicion is high but radiographic findings are equivocal. The higher degree of sensitivity of bone scanning is useful in detecting stress fractures and other forms of periosteal injury without complete fracture. • In patients presenting with hip pain and negative findings during the initial workup, obtaining plain radiographs of the ipsilateral knee also should be considered. Referred pain along the course of the anterior branch of the obturator nerve may manifest as ipsilateral hip pain and should be in the clinician's differential diagnosis, especially in younger patients.

Indications • Surgical treatment is warranted for all stress fractures that have progressed to a transverse fracture of the femoral neck. The question then becomes which treatment procedure is more beneficial to the patient. The orthopedist may choose either internal fixation or arthroplasty. The decision-making process should include consideration of the patient's bone quality, life expectancy, physiologic status, and overall activity level. However, the main factor in deciding which type of repair to undertake should be the likelihood of revision surgery being needed in the future for a failed arthroplasty. For most younger individuals in otherwise good health, this means internal fixation of the fracture is warranted. • Indications for hemiarthroplasty include such factors as pathologic bone, rheumatoid arthritis, renal failure or other chronic illness, and limited lifespan.

Contraindications • In general, nondisplaced, compression-type femoral neck fractures are relative contraindications to surgery. In contrast, tension-type stress fractures demand surgical treatment because they have a high propensity for fracture displacement. Contraindications to surgical fixation of a tension-type femoral neck fracture are few because this is one of the few true orthopedic surgical emergencies. If a displaced femoral neck fracture occurs, the very real possibility of disruption of blood supply to the femoral head makes surgery necessary. Absolute contraindications include a medically unstable patient who would be unable to tolerate the stress of surgery and anesthesia. If initial operative fixation is not obtained and osteonecrosis ensues, the patient, when stabilized, will require a hemiarthroplasty as definitive treatment.

Laboratory Studies • No particular laboratory studies aid in the diagnosis of this disorder; however, a prudent part of the preoperative workup is the ordering of standard laboratory tests (eg, blood chemistries, hemoglobin and hematocrit values, and coagulation profile). When an insufficiency fracture is suspected, the medical workup should include a search for metabolic abnormalities, including abnormal calcium, phosphate, and alkaline phosphatase values. • If septic arthritis of the hip is suspected, a C-reactive protein level, erythrocyte sedimentation rate, and WBC count with differential should help rule out an infectious process.

Imaging Studies • Plain radiography remains the initial imaging examination in the evaluation of suspected hip disease. A standard hip radiographic series includes an AP view of the pelvis and coned-down AP and frog-lateral views of the affected hip. • The AP view of the pelvis allows evaluation of the contralateral hip for concomitant disease and can be used to exclude osseous or articular abnormalities of the pelvis (eg, sacroiliitis, sacral stress fractures, pubic ring fractures) that could present clinically as hip pain. The AP views of the pelvis and hip are obtained with the feet internally rotated. • The frog-lateral view of a hip is obtained with the radiographic beam oriented in the AP direction, with the hip abducted. A groin lateral view of the hip, instead of the frog-lateral view, can be used in cases of an acute femoral neck fracture or displaced fracture, because the affected hip remains in a neutral position. In this examination, the opposite leg is abducted and elevated and the radiographic beam is oriented parallel to the table, with 20° cephalad angulation.

Imaging Studies • In the case of a compression-type fracture, the inferior aspect of the femoral neck demonstrates cortical thickening with a hazy, radiolucent center. This radiographic picture may be easily confused with osteoid osteoma if an adequate history is not obtained from the patient. Transverse-type fractures appear much differently on radiography, the first sign being a faint line of sclerosis across the femoral neck. If left untreated, these transverse fractures may easily progress to complete neck fractures, with significant displacement and varus angulation. • Because of its sensitivity in detecting periosteal injury, bone scanning has been very helpful in the absence of conventional radiographic findings. In the presence of stress fractures, bone scanning demonstrates focal increased uptake of the radiotracer, at the fracture site. This represents an area of increased bone turnover. One drawback to this modality, however, is that findings on scintography are often negative during the first 24 hours after stress fracture. The positive predictive value of radionuclide imaging in diagnosing femoral neck stress pathology approaches 68%.

Imaging Studies • Having similar sensitivity and the added advantage of greater specificity for stress fractures, MRI has become the new modality of choice for detecting stress pathology. In several studies, both the sensitivity and specificity of MRI in detecting femoral neck stress fractures was 100%. However, with this increased specificity comes increased price for the testing modality. In addition to being less invasive than bone scanning (no radiotracer needs to be injected), MRI provides much more information about the surrounding soft tissues. MRI has been shown to be effective in differentiating stress fracture from malignancy or infection. • A diagnostic MRI of a femoral neck stress fracture depicts decreased signal intensity on T1-weighted images and increased signal intensity on T2, as well as short TI inversion recovery (STIR) images with or without a low signal fracture line.

Outcome and Prognosis • he prognosis for femoral neck stress fractures depends largely on the classification of the fracture. Compression-type injuries historically fare very well, with the patient recovering full preinjury function after diligent adherence to a physician-prescribed plan of limited weightbearing and walking with an aid. Transverse-type fractures, when identified early and with the only radiographic abnormality being sclerotic changes, tend to recover well after internal fixation. Potential lasting effects of surgical management include hip pain and nonunion or malunion of the fracture. The worst prognosis exists for transverse fractures that are inherently unstable because of mechanical reasons and that can progress to complete displaced fractures. The rate of nonunion and AVN in these cases is as high as 35%, according to some authors.

Future and Controversies • Debate currently exists over the surgical treatment of transverse-type femoral neck stress fractures in older patients. Given that most individuals who sustain true stress fractures (as distinguished from insufficiency fractures) are young and healthy, only a small number of individuals are affected by this controversy. • The 2 current methods of fixation include internal fixation and prosthetic replacement. Multiple studies comparing the 2 modalities of fracture fixation for these types of injuries have demonstrated widely varying results. Infection rates, morbidity, mortality, and patient satisfaction have been examined without a definitive answer gleaned. Additionally, the prosthetic opponents point out that the cost and potential complications of the components are not justifiable for individuals whose remaining life expectancy might be half that of the implant.

Anteroposterior and lateral images of a 54-year-old woman with a 2-month history of right groin pain with ambulation. Note sclerosis of the right femoral neck running perpendicular to trabeculae.

Pelvic Fractures

Problem • Unstable pelvic fractures typically occur as a result of high-energy injuries. Associated organ system injuries are observed commonly with pelvic fractures due to the energy imparted to the patient. Head, chest, and abdominal injuries frequently occur in association with pelvic fractures. Fractures of the extremities and spinal column also can occur in patients with pelvic fractures. • Hemorrhage may accompany pelvic fractures. Most hemorrhage associated with pelvic fractures occurs as a result of bleeding from exposed fractures, soft tissue injury, and local venous bleeding (Huittinen, 1973). Arterial injuries also may contribute to hemorrhage with pelvic fractures albeit less commonly than venous bleeding (Schield, 1991). • Unstable and displaced pelvic ring disruptions cause significant deformity, pain, and disability. Deformities resulting from pelvic ring injuries include any combination of rotational and translational deformities. Significant permanent (sustained) pelvic deformities have been identified in poorer patient outcomes and decreased activity levels (Failinger, 1992; McLaren, 1990; Pohlemann, 1994).

Frequency • The incidence of pelvic fractures in the United States has been estimated to be 37 cases per 100,000 person-years. The incidence of pelvic fractures is greatest in people aged 15-28 years. In persons younger than 35 years, males sustain more pelvic fractures than females; whereas in persons older than 35 years, women sustain more pelvic fractures than men (Melton, 1981). Most pelvic fractures that occur in younger patients result from high-energy mechanisms, whereas pelvic fractures sustained in the elderly population occur from minimal trauma, such as a low fall (Melton, 1981).

Etiology • Pelvic fractures occur after both low-energy and high-energy events. Low-energy pelvic fractures occur commonly in 2 distinct age groups: adolescents and the elderly. Adolescents typically present with avulsion fractures of the superior or inferior iliac spines or apophyseal avulsion fractures of the iliac wing or ischial tuberosity resulting from an athletic injury. Low-energy pelvic fractures in the elderly frequently result from falls while ambulating, which are highlighted by stable fractures of the pelvic ring. Elderly patients also may present with insufficiency fractures, typically of the sacrum and anterior pelvic ring (Gotis-Graham, 1994). • High-energy pelvic fractures most commonly occur after motor vehicle crashes. Other mechanisms of high-energy pelvic fractures include motorcycle crashes, motor vehicles striking pedestrians, and falls.

Indications • Management of pelvic fractures in the immediate setting is centered on controlling life-threatening injuries, particularly severe hemorrhage. Several techniques have been used to control hemorrhage; these techniques are based on decreasing the volume of the pelvis, thereby limiting the amount of blood that can escape into the pelvic cavity. • Perhaps the simplest method to decrease pelvic volume is securely wrapping a sheet around the patient's pelvis. External fixators and other external pelvic clamps have been advocated to control pelvic volume, with the added benefit of providing bony stability, thereby preventing fracture movement and dislodgment of clots (Tile, 1988). Pneumatic antishock garments also have been used to control hemorrhage associated with pelvic fractures. Care must be taken when using pneumatic antishock garments as they increase intramuscular and intrathoracic pressure, potentially leading to compartmental syndrome and respiratory compromise distress. Pneumatic antishock garments are contradicted in patients with pulmonary edema and/or diaphragmatic rupture (American College of Surgeon's Committee on Trauma, 1993).

Tile classification scheme for pelvic fractures is as follows (Tile, 1995): • Type A - Rotationally and vertically stable • A1 - Avulsion fractures • A2 - Stable iliac wing fractures or minimally displaced pelvic ring fractures • A3 - Transverse sacral or coccyx fractures • Type B - Rotationally unstable and vertically stable • B1 - Open-book injuries • B2 - LC injuries • B3 - Bilateral type B injuries • Type C - Rotationally unstable and vertically unstable • C1 - Unilateral injury • C2 - Bilateral injuries in which one side is a type B injury and the contralateral side is a type C injury • C3 - Bilateral injury in which both sides are type C injuries

Laboratory Studies • A complete blood cell count, renal panel, coagulation profile, and toxicology screens usually are obtained in the emergency department upon patient presentation. Serial hematocrits are helpful in the acute setting to monitor resuscitation efforts.

Imaging Studies • Anteroposterior pelvic radiograph • Obtained as component of the initial trauma evaluation • Highlights most major pelvic disruptions (Young, 1987) • Inlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980) • X-ray tube angled 45° caudad and centered on the umbilicus • Highlights AP and mediolateral translations, and internal and external rotatory deformities • Outlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980) • X-ray tube angled 45° cephalad and centered on the symphysis pubis • Highlights superior and inferior translations abduction and/or adduction, and flexion and/or extension rotational deformities • Lateral sacral radiograph (Nork, 2001; Roy-Camille, 1985) • Indicated in injuries sustained from falls and when bilateral sacral fractures are noted on plain radiographs or CT scans • Demonstrates transverse fracture of sacral body and /or kyphosis of sacrum

Imaging Studies • Pelvic CT scans • Useful to confirm plain film findings and more to document sacral morphology when planning percutaneous iliosacral screw placement (Routt, 2000) • Often can be included with abdominal CT scans • Five-millimeter axial images from iliac crests to acetabular dome, then 3-mm axial images including all acetabular articular segments, then 5-mm slices through remainder of caudal pelvis (Routt, Orthop Clin North Am, 1997) • Three-dimensional reformatted pelvic CT scans also may be beneficial to highlight pelvic ring injuries and associated deformity patterns. • Pelvic angiograms • Indicated in patients with ongoing hemorrhage after adequate intravenous fluid resuscitation and provisional pelvic ring stabilization • Useful in patients who have pelvic ring or acetabular injuries involving the greater sciatic notch to detect obvious or occult injury to the superior gluteal artery • Embolization of lacerated arterial vessels may be performed at the same setting, as can manipulative reductions using the angiography fluoroscopic imaging system

Imaging Studies • Retrograde urethrogram • Indicated in patients suspected of having urethral tears • Recommended to be performed under the direction of a urologist • Cystogram • Indicated in patients suspected of having a urinary bladder injury • Recommended to be performed under the direction of a urologist

Medical Therapy • Initial therapy in the acutely injured patient centers on the ABCs as recommended by ATLS protocols published by the American College of Surgeons (American College of Surgeon's Committee on Trauma, 1993). The following mnemonic defines the specific, ordered, prioritized evaluations and interventions that should be followed in injured patients (American College of Surgeon's Committee on Trauma, 1993): • A = Airway with cervical spine control • B = Breathing • C = Circulation • D = Disability or neurologic status • E = Exposure (undress) with temperature control • After initial resuscitation and stabilization, other non–life-threatening injuries are evaluated and managed appropriately. Following these guidelines, under the direction of a trauma surgeon or general surgeon, patient treatment is optimized.

Surgical Therapy • Symphysis pubis disruptions • Letournel recommended operative stabilization of symphyseal disruptions when the pubic diastasis measured greater than 1.5 cm (Letournel, 1978). Routt et al also noted that children and people of smaller stature may demonstrate rotational pelvic instability with pubic diastases less than 2.5 cm (Routt, Orthop Clin North Am, 1997). It has been observed that a symphysis pubis diastasis may increase after administration of general anesthesia, implying that plain radiographs may underestimate the actual deformity due to associated muscle spasm.

Pubic ramus fractures • Pubic ramus fractures occur as parasymphysial fractures, midramus fractures, and pubic root fractures in association with distraction and compression injuries of the pelvis (Routt, Orthop Clin North Am, 1997). Displacement of pubic rami fractures may cause impingement or laceration of the bladder, vagina, and perineum, and, for these reasons, operative management may be considered. Operative treatment of pubic rami fractures is indicated to provide additional pelvic ring stability in association with posterior pelvic ring fixation. Stabilization of pubic rami fractures also may be considered in fractures involving the obturator neurovascular canal with accompanying neurologic injury. • Treatment options for pubic rami fractures include external fixation, percutaneous screw fixation, and open reduction and internal fixation. External fixation with either multiple pins (Kellam, 1989) or single pins in each hemipelvis (Tucker, 2001) may be used successfully in conjunction with stabilization of posterior ring injuries to impart additional stability to the pelvic fixation construct. External fixation for pubic ramus fractures is indicated to impart additional stability after posterior pelvic ring repair and also when percutaneous or open treatment is contraindicated. • Intramedullary fixation of pubic ramus fractures has been described for treatment of pubic rami fractures (Simonian, J Orthop Trauma 1994;8(6):476-82; Tile, 1995). Intramedullary pubic ramus fixation with a 4.5-mm cortical screw has demonstrated fixation strength equivalent to plate fixation and has demonstrated good results in clinical settings (Routt, 2000; Simonian, J Orthop Trauma 1994;8(6):483-9). Intramedullary stabilization of ramus fractures may be performed with either a percutaneous or open technique with either antegrade or retrograde screw placement in the pubic ramus. Extramedullary plate fixation is another option to stabilize pubic rami fractures after open reduction and usually is achieved with 3.5-mm pelvic reconstruction plates.

Iliac wing fractures • liac wing fractures are caused by forces applied directly to the iliac wing. Simple fracture patterns without associated pelvic ring instability are managed with nonoperative measures. Comminuted iliac wing fractures are caused by high-energy injuries, and severe soft tissue injury, including open wounds, frequently accompany these injuries (Switzer, 2000). • Indications for operative management of iliac wing fractures include associated skin abnormalities, significant closed degloving injuries, and open wounds. Severely displaced or comminuted iliac wing fractures, unstable iliac fractures that preclude adequate pulmonary function secondary to pain, bowel herniation or incarceration within the fracture, and fractures associated with unstable pelvic ring injuries are other indications for open reduction and internal fixation (Routt, Orthop Clin North Am, 1997; Switzer, 2000). Preoperative pelvic angiograms are recommended for fractures involving the greater sciatic notch. • The lateral window of the ilioinguinal surgical exposure is used to access iliac wing fractures. After fracture exposure, tenaculum clamps, Farabeuf clamps, and Schanz pins used as joysticks are used to obtain fracture reduction. Fracture reduction is maintained with medullary lag screws in combination with pelvic reconstruction plates for definitive stabilization. For patients with open iliac fractures, the fixation construct should rely on medullary screws in order to seclude the implants from contamination.

Crescent fractures • Treatment of crescent fractures with the patient in the supine position allows for direct reduction of the SI joint and indirect reduction of the iliac fracture (Lange, 1990). The lateral window of the ilioinguinal surgical exposure is used to access the SI joint. After the SI joint is visualized and debrided, reduction is performed under direct visualization using a combination of clamps, external fixators, and, occasionally, a femoral distractor used in compression. The SI joint is stabilized with iliosacral screws, 3.5-mm reconstruction plates placed perpendicular to one another, or both used in combination (Routt, Orthop Clin North Am, 1997).

Sacroiliac joint disruptions • Stabilization is achieved with either 3.5- or 4.5-mm pelvic reconstruction plates placed perpendicular to one another across the SI joint. Plates should be contoured carefully to avoid distraction at the inferior portion of the SI joint (Routt, 1997). The S1 nerve root is at risk when drilling and inserting a screw within the sacral ala, and fluoroscopic guidance is recommended. • Stabilization of SI disruptions from the prone position uses a vertical paramedian dorsal surgical exposure; however, one must be wary of significant wound problems that may develop using posterior exposures in a compromised soft tissue envelope (Goldstein, 1986; Kellam, 1989). Unlike anterior surgical exposures, reduction of the SI joint is performed indirectly because visualization is compromised as the joint is brought into reduction. Reduction is verified manually by palpation of the anterior aspect of the SI joint through the greater sciatic notch and radiographically with intraoperative fluoroscopic imaging. Reduction of the dislocated ilium to the sacrum may be assisted with clamps placed through the greater sciatic notch clamping the posterior iliac wing to the sacral ala (Matta, 1989; Moed, 1998). Stabilization is obtained with combinations of transiliac plates using either pelvic reconstruction or dynamic compression plates, transiliac screws, and iliosacral screws.

Sacral fractures • Sacral fractures usually are treated by indirect reduction techniques unless a need for foraminal decompression is present or an acceptable reduction cannot be obtained by closed manipulative means. Open treatment is performed in the prone position using a vertical paramedian dorsal surgical exposure. Direct access to the posterior sacrum is achieved by elevating the paraspinal muscles from the sacrum, whereby decompression of sacral foramina may be accomplished. After fracture reduction, stabilization is obtained with transiliac bars, transiliac screws, transiliac plates, or iliosacral screws. Despite the implant, care must be taken not to over compress the sacral fractures and potentially create an iatrogenic sacral nerve root injury.

Complications • Muscle ruptures and hernias • Neurologic injury • Postoperative wound infection • Proximal DVTs • Genitourinary

Basic principles of treatment of breaks of lower extremity and pelvis.