Pelvic Ring Injuries Definitive Treatment

1. Pelvic Ring Injuries Definitive Treatment Steven A. Olson, MD Rafael Neiman, MDCreated March 2004Reviewed April 2007

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

3. 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

4. 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

5. 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

6. 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 theinability to sustain loads required for patient mobilization without significant displacement or deformation

7. 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

8. 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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. 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’)

25. Techniques • PubicRamus 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)

26. 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

27. 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

28. 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 requireoperative reduction and fixation; often they cannot be reduced by closed means due to interposing SI joint ligaments and capsule

29. 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)

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

35. 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)

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. Matta, Surgical Approaches to the Acetabulum

44. Matta, Surgical Approaches to the Acetabulum

45. 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

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

47. 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

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

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

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