You are in: eMedicine Specialties > Orthopedic Surgery > HIP Pelvic FracturesArticle Last Updated: May 18, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: George V Russell, Jr, MD, Assistant Professor, Department of Orthopedic Surgery and Rehabilitation, University of Mississippi Medical Center George V Russell Jr is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, National Medical Association, Orthopaedic Trauma Association, Southern Medical Association, and Southern Orthopaedic Association Coauthor(s): Christopher A Jarrett, MD, Fellow in Adult Reconstruction, Department of Orthopedic Surgery, Lenox Hill Hospital; ML Chip Routt, Jr, MD, Professor, Department of Orthopedics, University of Washington School of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, Harborview Medical Center, University of Washington Medical Center Editors: B Sonny Bal, MD, Associate Professor, Department of Orthopedic Surgery, University of Missouri School of Medicine; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; James J McCarthy, MD, FAAOS, FAAP, Associate Professor, Consulting Orthopedic Surgeon, Department of Orthopedics and Rehabilitation, University of Wisconsin School of Medicine and Public Health;; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; William L Jaffe, MD, Clinical Professor of Orthopedic Surgery, New York University School of Medicine; Vice Chairman, Department of Orthopedic Surgery, New York University Hospital for Joint Diseases Author and Editor Disclosure Synonyms and related keywords: pelvic fractures, pelvic ring injuries, broken pelvis, cracked pelvis, shattered pelvis, fractured hip, broken hip INTRODUCTIONSection 2 of 11
  History of the ProcedurePelvic fractures historically have been treated nonoperatively. The earliest management of pelvic fractures consisted of prolonged recumbency followed by mobilization as fracture healing occurred and symptoms abated. Other methods also used to treat pelvic fractures included closed reduction under general anesthesia, traction, spica casts, pelvic slings, and turnbuckles (Dunn, 1968; Holdsworth, 1948; Holm, 1973; Watson-Jones, 1938). Operative management of unstable pelvic injuries increased especially recently due to several factors. Improved and coordinated treatment of polytraumatized patients, improved anesthetic techniques including blood salvage systems, advances in intraoperative fluoroscopic imaging techniques, standardized pelvic implant system, and better understanding of injury and deformity patterns have allowed for successful operative treatment of patients with pelvic ring injuries. Operative management of unstable pelvic ring injuries allows for earlier patient mobilization, thereby decreasing complications associated with recumbency. Operative management also allows for correction and prevention of significant pelvic deformities, improving clinical outcomes. ProblemUnstable 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). FrequencyThe 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). EtiologyPelvic 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. ClinicalDue to the fact that most unstable and displaced pelvic ring injuries fractures occur as the result of high-energy mechanisms, many patients present with associated primary organ system injuries. A careful assessment of the patient must begin with an examination for immediate life-threatening injuries. Assessment should begin in an orderly fashion to avoid missing injuries. The American College of Surgeons has popularized Advanced Trauma Life Support (ATLS), a program that provides a systematic and orderly treatment protocol for traumatized patients under the direction of a general surgeon or trauma surgeon (American College of Surgeon's Committee on Trauma, 1993). This protocol has been used successfully at many trauma centers and is recommended by the authors. Soft tissue injuries provide an indirect measurement of the energy sustained by the patient. Scrotal, labial, flank, and inguinal hematomata commonly accompany pelvic ring injuries and are indicative of intrapelvic hemorrhage (Peltier, 1965). Soft tissue injury is observed along a continuum from superficial abrasions and lacerations to closed internal degloving injuries (Hak, 1997), to open wounds. Lacerations of the perineum must be carefully sought during the initial physical examinations and secondary surveys. Rectal and vaginal lacerations may be overlooked due to the initial examination's concentration on more obvious injuries. Rectal, vaginal, and perineal lacerations are indicative of severe injuries and indicate likely fracture contamination by urine, stool, and other environmental contaminants. Manual palpation of the pelvis should be included in assessing patients with pelvic ring injuries. Palpation must be undertaken carefully to avoid harming the patient. Manual palpation can reveal crepitus from fractures and assists with determination of pelvic stability. Manual compression along the iliac crests provides a tactile assessment of pelvic ring stability. Contralateral push-pull examinations of the lower extremities are rarely necessary to identify instability. Blood at the external urethral meatus is indicative of a urethral disruption. Perineal and genital swelling also reflect urethral disruption. Digital rectal examination may reveal a high-riding prostate gland in the male, which also is suggestive of a urethral disruption. Bladder disruptions occur frequently with pelvic fractures and may be intraperitoneal, extraperitoneal or both. Gross hematuria is the most common clinical finding supporting a diagnosis of a bladder disruption (Watnik, 1996). The presence of gross hematuria demands evaluation of the lower genitourinary (GU) system under the direction of a urologist. Axial and appendicular skeletal injuries are frequently associated with pelvic ring injuries fractures. Careful examination of the spine and extremities is indicated as part of complete patient evaluation. Particular attention to the lower extremities may demonstrate limb length discrepancies associated with superior hemipelvic translations. Internal and/or external rotational deformities resulting from deformities of the pelvis may be noted by similar deformities in the lower extremities. Injuries to the pelvic ring may cause injury to any of the neurovascular structures that traverse the pelvis. Vascular injuries are usually lacerations of venous structures (Huittinen, 1973). Arterial injuries also occur but much less frequently than venous injuries (Schield, 1991). Despite the source of bleeding, venous or arterial, each may contribute to hemorrhage and demand emergent or urgent management. Neurologic injuries typically occur as injuries to the L5 or S1 nerve roots (Huittinen, 1972; Huittinen, 1973). L4 nerve root injuries also may occur with severe pelvic ring injuries. Sacral fractures frequently accompany pelvic ring fractures and may have S2-S5 sacral nerve root injuries. Lower sacral nerve root injuries may lead to bowel and bladder incontinence and sexual dysfunction. Detection of these nerve injuries is difficult acutely, but careful examination may demonstrate perineal numbness and decreased rectal tone in the acute period. INDICATIONSSection 3 of 11
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). The primary goal for the treatment of pelvic fractures in the acute setting is to provide early stable fixation to allow for patient mobilization. Several studies have demonstrated beneficial effects with early pelvic fracture treatment such as decreased blood transfusion requirements, decreased systemic complications, decreased hospital stays, and improved patient survival (Goldstein, 1986; Latenser, 1991). Secondary considerations for operative management of pelvic fractures in the acute setting are the correction or prevention of significant pelvic translational and rotational deformities that have been associated with poorer clinical outcomes (McLaren, 1990; Slatis, 1972; Tilem, 1988). Several classification systems have been developed to assist with injury pattern recognition and management decisions; perhaps the best known are those described by Tile and Burgess et al (Burgess, 1990; Tile, 1995). Both of these classification schemes provide recommendations for management of pelvic fractures based on the function of the posterior ligamentous structures to support the pelvic ring. Others prefer to describe injuries based on the anatomic location of the pelvic ring injuries and the associated displacements and instabilities (Routt, Orthop Clin North Am, 1997). Pennal and Tile developed a classification scheme for pelvic fractures, which described injuries to the pelvic ring based on the vector of the deforming force and divided these into lateral compression (LC) injuries, anteroposterior compression (APC) injuries, and vertical shear injuries (Pennel, Tile, Waddell, Garside, 1980). Tile further modified this classification scheme to include radiographic signs of pelvic stability or instability. Type A injuries are classified as those that are rotationally and vertically stable. Type B injuries are categorized as those injuries that are rotationally unstable but vertically stable. Type C injuries are rotationally and vertically unstable (Tile, 1995). Tile classification scheme for pelvic fractures is as follows (Tile, 1995):
Young and Burgess further expanded the classification of Tile by adding a combined mechanism category in recognition that many pelvic fractures result from a combination of vectors. Their classification divided LC and APC fractures into subgroups I, II, and III, which are based on the amount of disruption based on anteroposterior (AP), inlet, and outlet pelvic radiographs. This classification facilitates stratification of the amount of energy imparted to the patient (Burgess, 1996; Burgess, 1990). This classification also has been demonstrated to be predictive of associated injury patterns based on the type of pelvic ring deformity (Dalal, 1989). Vertical shear fractures are characterized by vertical rami fractures or a diastasis of the symphysis pubis anteriorly and vertical displacement of the posterior pelvic ring through the sacroiliac (SI) joint, sacrum, or ilium. Combined mechanism fractures are characterized by a combination of the above-mentioned injury patterns. RELEVANT ANATOMYSection 4 of 11
The pelvic ring consists of 2 innominate bones connected anteriorly at the symphysis pubis and posteriorly to the sacrum at the SI joints. Anatomically, the pelvis is divided into the false pelvis and the true pelvis. The false pelvis is defined as that portion of the pelvis from the iliac crests superiorly to the pelvic brim inferiorly. The true pelvis is defined from the pelvic brim inferiorly to the pelvic floor. Pelvic ligamentsThe bones of the pelvis are held together by strong ligaments and can be divided into 4 groups: those connecting the sacrum and ilium; those connecting the sacrum and ischium; those connecting the 2 pubic bones at the symphysis pubis, and those uniting the sacrum and coccyx (Burgess, 1996). The anterior and posterior SI ligaments link the iliac bones to the sacrum. Two distinct bands demarcate the posterior SI ligaments. The short posterior interosseus ligaments consist of fibers running from the ridge of the sacrum to the posterior superior and posterior inferior iliac spines. The long posterior SI ligament consists of fibers originating from the posterior superior iliac spine, which then intermingle with originating fibers of the sacrotuberous ligament, covering the short posterior SI ligament and attaching to the lateral sacrum. The anterior SI ligaments consist of fibrous bands that join the anterior surface of the sacrum to the adjacent anterior ilium (Burgess, 1996). The sacrospinous and sacrotuberous ligaments connect the sacrum to the ischium. The sacrospinous ligament, originating from the lateral margin of the inferior sacrum and attaching at the ischial spine, assists in resisting external rotation forces of the pelvis (Tile, 1995). The sacrotuberous ligament has a broad origin from the posterior superior and posterior inferior iliac spines and the entire lateral margin of the posterior sacrum. The sacrotuberous ligament courses posteriorly to the sacrospinous ligament inserting on the ischial tuberosity. The sacrotuberous ligament resists sagittal plane rotational deformities and vertical shearing of the pelvis (Tile, 1995). The symphysis pubis is a movable articular joint without a synovial membrane. An interpubic disk, the superior pubic ligaments, and the arcuate ligaments inferiorly connect the pubic bones. The remainder of the ligaments that surround the pelvis are ligaments that do not have significant stabilizing roles for the pelvis, including ligaments connecting the sacrum and coccyx, the lateral lumbosacral ligaments originating at the L5 transverse processes and attaching to the sacral ala, and the iliolumbar ligaments, running from the L5 transverse processes to the iliac crests (Tile, 1995). Pelvis as conduit for neurovascular structuresThe pelvis acts to connect the axial skeleton with the appendicular skeleton of the lower extremities and, in this role, serves as a conduit for neurovascular structures. Vascular structures The common iliac blood vessels enter into the false pelvis, in which the division into the external and internal iliac vessels occurs. The external iliac vessels continue through the false pelvis atop the pubic rami medial to the iliopectineal eminence. The internal iliac vessels dive into the pelvis, in which they divide into somatic branches, visceral branches, and limb and perineal branches. Other vessels of the pelvis include the terminal branch of the aorta, the median sacral artery, and the superior rectal artery, a continuation of the inferior mesenteric artery (Burgess, 1996). Somatic segmental branches (Burgess, 1996) are as follows:
Visceral branches are as follows:
Limb and perineal branches are as follows:
Neurologic structures The neurologic contents of the pelvis collectively have been referred to as the lumbosacral plexus. This consists of what are individually known as the lumbar plexus and the sacral plexus. Anatomically, the lumbar plexus is an abdominal structure whose branches enter the pelvis. Conversely, the sacral plexus is entirely pelvic in origin. The lumbar plexus consists of nerve roots from L1-L4. The sacral plexus consists of those more caudal nerve roots. Each plexus can be divided into ventral and dorsal branches. The larger nerves of the pelvis originate from the sacral plexus. The most cephalic of the nerves of the pelvis are the ilioinguinal and iliohypogastric nerves. These originate from the L1 nerve root. Both enter the pelvis on the surface of the psoas muscle, which they cross obliquely as they travel distally. They penetrate the abdominal wall muscles to serve as cutaneous innervation of the areas surrounding the pelvis. The iliohypogastric nerve supplies the skin of the posterolateral buttock, while the ilioinguinal nerve supplies the root of the penis and scrotum (Burgess, 1996). The lumber plexus can be divided into nerves consisting of dorsal or ventral branches. The psoas muscle anatomically separates these nerves. The femoral and lateral femoral cutaneous nerves are the primary dorsal branches of the lumbar plexus. The femoral nerve (L2, 3, 4) lies lateral to the psoas between the psoas and the iliacus muscles as it enters the pelvis over the iliac wing (Burgess, 1996). It innervates the iliacus muscle then exits the pelvis beneath the inguinal ligament to supply both motor as well as sensory fibers to the anterior compartment of the thigh (Clemente, 1981). The lateral femoral cutaneous nerve also emerges lateral to the psoas. It travels over the iliacus and becomes superficial to supply sensation to the lateral thigh (Burgess, 1996). The ventral branches of the lumbar plexus are represented in the obturator nerve (L2, 3, 4). The obturator nerve appears medial to the psoas just above the pelvis, it then enters the pelvis, with the vertebral column on its medial side and the psoas lateral to it. The obturator nerve travels with the internal iliac vessels and the ureter on the lateral pelvic wall. Running coursing along the surface of the obturator internus muscle, the obturator nerve then leaves the pelvis through the obturator canal (Burgess, 1996). Its main function is to provide motor innervation to the adductors of the thigh (Clemente, 1981). The branches of the sacral plexus originate in the pelvis in which the sacral plexus lies anterior to the piriformis muscle. The nerves of the plexus can be divided into ventral and dorsal branches. All of which exit the pelvis through the greater sciatic foramen notch. All branches pass below the piriformis muscle except the superior gluteal nerve (L4, 5, S1), which exits above the piriformis (Burgess, 1996). The dorsal branches of the plexus include the superior (L4-S1) and inferior (L5-S2) gluteal nerves and the common peroneal portion of the sciatic nerve (L4-S2). The anterior or ventral divisions supply the calf, plantar foot, and thigh through the tibial nerve (L4-S3) (Hollinshead, 1982). Muscles groups around the pelvisSeveral important muscle groups are around the pelvis. The muscles of the pelvic floor, the levator ani muscle, and the coccygeus muscles are composed of voluntary muscles, which support the pelvic viscera and control the voluntary sphincters of the rectum and urethra (Anson, 1966). Additionally, the muscles of the pelvic floor have been noted to impart stability to the pelvic ring (Tile, 1988). Another muscle around the pelvis includes the piriformis muscle, which is an important anatomic landmark demarcating the division of the superior and inferior gluteal vessels and assisting with identification of the sciatic nerve. Many other muscles originate and insert on the bones of the pelvis, a discussion of which is beyond the scope of this article and can be referenced from anatomy textbooks. CONTRAINDICATIONSSection 5 of 11
For contraindications to specific surgical procedures, see Surgical therapy. WORKUPSection 6 of 11
Lab Studies
Imaging Studies
TREATMENTSection 7 of 11
Medical therapyInitial 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):
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 therapySymphysis pubis disruptions Disruptions of the symphysis pubis are typically described as resulting from an anterior or posterior force impacting the pelvis; however, laterally directed compressive forces also have been implicated in creating symphyseal disruptions (Routt, Orthop Clin North Am, 1997; Tile, 1988). Indications to operatively stabilize symphysis pubis disruptions are determined by the amount of instability between the pubic bones. Several authors have recommended operative stabilization when the pubic diastasis is greater than 2.5 cm, based on experimental evidence demonstrating that pubic bone displacement greater than 2.5 cm implies rupture of the anterior sacroiliac, the sacrospinous, and the sacrotuberous ligaments rendering the pelvis rotationally unstable (Burgess, 1990; Tile, 1988). 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. Treatment options for symphyseal disruptions consist of external fixation or more mechanically sound open reduction with internal fixation. Anterior pelvic external fixation can be used in patients with small symphyseal disruptions with incomplete posterior ligamentous injury (Kellam, 1989; Letournel, 1978; Routt, Orthop Clin North Am, 1997). The use of an anterior external fixator is potentially beneficial because it avoids operative exposures, potential bleeding from venous plexus injuries, and bladder perforation associated with open stabilization (Kellam, 1989). The external fixator is also useful to avoid wound contamination when suprapubic catheters are in place for the treatment of urinary bladder disruptions. The external fixator should remain in place until healing is demonstrated, which usually occurs between 6 and 12 weeks postoperatively (Kellam, 1989; Letournel, 1978). External pelvic fixation is cumbersome for patients and is associated with pin track infections and even iliacosteomyelitis. Open reduction and internal fixation is preferred for unstable symphyseal injuries. Open reduction and internal fixation avoids the inconvenience of wearing and removing an external fixator. Surgical stabilization is performed through a Pfannenstiel surgical exposure, or an extension of a midline exposure may be used. Tenaculum clamps, Farabeuf clamps, and pelvic reduction clamps may be used to reduce the pubic diastasis. Implants commonly used to stabilize symphyseal disruptions are 3.5-mm reconstruction plates, 4.5-mm reconstruction plates, 3.5-mm low-contact dynamic compression plates, and 4.5-mm low-contact dynamic compression plates. Regardless of the plate used, at least 2 screws should be placed on each side of the defect to prevent subsequent rotatory deformities. The larger plates do not fit the symphyseal area well and for this reason, 3.5-mm pelvic reconstruction plates are preferred. 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 Iliac 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 Crescent fractures, are actually fractures of the posterior ilium extending from the iliac crest into the greater sciatic notch and associated with an articular dislocation of the anterior sacroiliac joint and commonly result after LC injuries to the iliac wing (Burgess, 1990) but also may occur secondary to anteriorly or posteriorly directed forces (Routt, Orthop Clin North Am, 1997). Crescent fractures typically result in a stable posterior iliac fragment and a rotationally unstable iliac component. The posterior iliac fragment is stable due to the attachment of the intact posterior SI ligaments, whereas the iliac component is rotationally unstable (Borrelli, 1996). When viewed laterally, the posterior iliac stable segment is crescent - shaped, hence the terminology. Surgical stabilization is indicated due to the inherent instability of the iliac wing component of the fracture and the dislocation of the SI joint. Crescent fractures may be treated with the patient positioned either prone or supine, depending upon associated pelvic ring injuries, acetabular fractures, soft tissue injuries, and the location of the crescent fracture. Fractures treated from the prone position are exposed with a vertical paramedian dorsal surgical approach, allowing direct reduction of the iliac fracture and indirect reduction of the SI joint. The iliac fracture is visualized directly, reduced with clamps, and stabilized with lag screws and 3.5-mm reconstruction plates along the iliac wing (Borrelli, 1996). Percutaneously placed iliosacral screws also may be used to supplement fixation. 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). Isolated percutaneous treatment of crescent fractures using iliosacral screw fixation can be used if the posterior iliac fracture fragment is small, the unstable iliac wing component can be reduced with closed manipulative means, and the sacral safe zone is large enough to accommodate an iliosacral screw (Routt, 2000). This technique can be used with either prone or supine positioning using well-described techniques for placement of iliosacral screws (Matta, 1989; Routt, J Orthop Trauma, 1997). Sacroiliac joint disruptions SI joint disruptions occur as a result of an anteriorly or posteriorly directed force to the pelvis associated with symphysis pubis disruptions or rami fractures (Failinger, 1992; Huittinen, 1972; McLaren, 1990). Incomplete disruptions of the SI joint typically are characterized by rupture of the anterior SI ligaments with a concurrent symphyseal disruption of less than 2.5 cm (Tile, 1988). These injuries are not associated with vertical instability and may be managed nonoperatively, with an external fixator or open reduction and internal fixation (Kellam, 1989; Tile, 1988). Complete disruptions or dislocations of the SI joint are associated with rupture of the anterior and posterior SI joint ligaments. A rotationally and/or vertically unstable pelvis characterizes these injuries. Because of the poor results with persistent SI joint subluxations and dislocations, surgical reduction and stabilization is recommended. Open treatment of SI joint disruptions can be performed from either the supine or prone position. Stabilization in the supine position usually is achieved using the lateral window of the ilioinguinal surgical exposure. After debridement of the joint space, the dislocation is reduced. Care must be taken with exposure across the SI joint to avoid excessive medial dissection to prevent injury to the L5 nerve root. Distal ipsilateral femoral traction, Schanz pins within the ilium, tenaculum clamps, Farabeuf clamps, pelvic reduction clamps, and a femoral distractor used in compression may all be helpful in reducing SI joint disruptions (Simpson, 1987). 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. Use of iliosacral screws has gained popularity for stabilization of SI joint disruptions. Percutaneously placed iliosacral screws have been used after both open and closed reduction of SI joint disruptions. Iliosacral screws may be placed in either the prone (Matta, 1989) or supine position (Routt, J Orthop Trauma, 1997) with good results. When using percutaneous techniques for posterior ring stabilization, it is helpful to reduce and stabilize the anterior pelvic ring injuries, which indirectly reduce the posterior ring, thereby allowing for safe iliosacral screw placement (Routt, 2000). Careful examination of plain radiographs and CT scans are essential in evaluating sacral morphology and planning for safe iliosacral screw placement (Routt, 2000). Cannulated iliosacral screws are inserted under fluoroscopic guidance using inlet, outlet, and lateral sacral images (Routt, 1996; Routt, 2000). Others prefer solid iliosacral screw placement, with which the tactile sensation of the drill bit engaging into the sacral ala and sacral body is used to assist with fluoroscopic imaging in safe placement of iliosacral screws (Matta, 1989; Templeman, Schmidt, Freese, Weisman, 1996). Still others favor CT scan–guided placement of iliosacral screws (Ebraheim, 1987; Nelson, 1991). Each technique has its advantages and associated potential problems but each demands that the surgeon understand the local anatomy and achieve accurate reductions. Sacral fractures Sacral fractures frequently occur with pelvic ring injuries. Sacral fractures commonly are classified by the location of the sacral fracture. Type I fractures involve the sacral ala, type II fractures involve the sacral foramina, and type III fractures involve the central portion of sacrum (Denis, 1988). Roy-Camille has further subclassified central sacral fractures (Roy-Camille, 1985). Operative stabilization of sacral fractures is indicated in those fractures that are displaced, those that lend themselves to pelvic ring instability, and those sacral fractures with foraminal debris causing a neurologic deficit. 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. Iliosacral screws may be placed in the supine or prone position to stabilize sacral fractures after closed manipulative means. Reduction and stabilization of associated anterior fractures facilitate reduction of sacral fractures, allowing for safe iliosacral screw placement (Routt, 2000). Contraindications to percutaneous iliosacral screw technique are an inability to obtain a reduction of the sacral fracture, sacral dysmorphism, or fractures of neural foramina requiring debridement. Neurodiagnostic monitoring should be considered when foraminal debris is present and/or foraminal decompression is undertaken. Several different types of monitoring have been used with good results, including somatosensory evoked potentials, continuous electromyographic monitoring, and stimulus evoked electromyography (Moed, 1998; Vrahas, 1992; Webb, 1996). Neurodiagnostic monitoring does not protect the patient from a surgeon with poor understanding of the anatomy and its radiographic correlations. Preoperative detailsPreoperative traction is a consideration for patients with displaced pelvic fractures to prevent large pelvic translations and provide patient comfort. Skeletal traction is preferred in the ipsilateral distal femur if not contraindicated. Ten to 30 pounds of traction is sufficient to meet the goals of provisional stabilization. Patients with injuries of the sciatic nerve should be splinted to avoid equinus deformities. Deep venous thrombosis (DVT) prophylaxis is recommended in the preoperative setting. Both mechanical and pharmacologic methods are available for DVT prophylaxis. Subcutaneous heparin, low molecular weight heparin, warfarin, and aspirin are all used for DVT prophylaxis. Compression hose and sequential compression devices also are used in combination with pharmacologic methods to prevent DVT formation. Internal venal caval filters are used occasionally when pharmacologic prophylaxis is contraindicated or a DVT has been detected. Consideration should be given to preoperative duplex ultrasonography, especially in patients with prolonged recumbency prior to surgery. A screening hematocrit must be obtained, and the patient must have a type and crossmatch prior to surgery. Cellsavers are valuable tools to decrease the need for blood transfusions and should be reserved in the preoperative period. Patients with neurologic injuries require special consideration in the preoperative period. Sciatic nerve palsies must be recognized, and splinting of the ankle is required to prevent equinus contractures. Injuries to all, or portions of, the lumbosacral plexus may occur with pelvic ring injuries. When possible, these injuries should be clearly documented in the preoperative setting to avoid confusion about potential iatrogenic injuries. Neurodiagnostic monitoring may be desirable, and should be arranged preoperatively if so. If intraoperative fluoroscopy is to be used and the patient has ingested oral contrast, an AP pelvic radiograph is recommended preoperatively to ensure that fluoroscopic visualization is adequate. Residual contrast should be evacuated prior to surgery and a repeat AP pelvic radiograph performed after bowel evacuation. Preoperative templating of plates to a skeletal model may prove beneficial by decreasing operative time and increasing operative efficiency. For example, transiliac plates are easily contoured to a skeletal model and after sterilization may be applied to the ilium with possible minor modifications. Intraoperative detailsThe operative table usually is chosen to allow for intraoperative fluoroscopic imaging, and a radiolucent table is recommended. For supine positioning, the patient is placed elevated on a lumbosacral support beneath the back along the axis of the spine which allows iliosacral screw insertions if needed. The arms are placed at 90° to the body on padded arm boards to allow for proper positioning of the C-arm. If traction is to be used, a traction apparatus from the table can be used, or traction may be applied by hanging the weights over the side of the table. Prone positioning is performed on the same table using padded chest rolls, which relieve abdominal pressure and allow ventilation. Pads are placed anterior to the knees, and pillows are placed anterior to the legs to elevate the toes off the table. The arms are placed in a flying position with 45° of shoulder abduction and neutral shoulder elevation. The elbows are flexed to 90°, and the hands are positioned pronated on the arm board. If neurologic monitoring is used, the setup should be performed preoperatively. The technician should establish the workings of the setup, and baseline values should be obtained. An understanding should exist between the examiner and the anesthesiologist regarding the type of anesthetic agents because neurologic recordings vary with certain anesthetics. Postoperative detailsPortable postoperative AP, inlet, and outlet pelvic radiographs are taken in the recovery room to assess pelvic ring reconstruction and implant safety. If a radiographic imaging is inferior using portable technique, then consideration should be given to taking radiographs in the radiology department on discharge from the recovery room. Postoperative CT scanning is recommended to assess pelvic ring reduction and implant safety, particularly when iliosacral screws are used. Pain control is important in the postoperative period to assist with patient mobilization. Epidural narcotics provide excellent pain relief in the acute postoperative period; however, one must be aware of potential epidural bleeding with concurrent anticoagulation. Patient-controlled analgesic machines work well to alleviate postoperative pain, and patients do not depend on nursing administration of narcotic analgesics. Long-acting oral narcotic medications may be useful as an adjunct to patient-controlled analgesia to provide sustained pain control. After discontinuation of intravenous narcotic medications, both long-acting and short-acting oral narcotics are used to manage postoperative pain. DVT prophylaxis is important postoperatively and should be managed aggressively. Mechanical methods, such as supportive stockings, work to decrease venous stasis, thereby decreasing the risk of DVT formation. Sequential compression devices also work to decrease venous stasis, but they also may have a role in stimulating the fibrinolytic system and stimulation of tissue factor pathway inhibitor release. (Montgomery, 1997) Pharmacologic prophylaxis consists of subcutaneous heparin, low molecular weight heparin, warfarin, and aspirin. The particular agent to choose is beyond the scope of this discussion, but evidence suggests that combined mechanical and pharmacologic prophylaxes may result in greater protection than either alone (Montgomery, 1997). Inferior vena caval filters may be placed in the perioperative setting for patients in whom pharmacologic DVT prophylaxis and treatment is contraindicated and also in patients with documented DVTs. Follow-upPatients are mobilized based on their particular injury pattern, with a goal of full weightbearing by 3 months postoperatively. After discharge from the hospital, patients are seen in follow-up 2 weeks postoperatively for a wound check. Patients are seen again 6 weeks postoperatively for repeat clinical and radiographic examination. Further postoperative visits are scheduled at 3, 6, and 12 months postoperatively. COMPLICATIONSSection 8 of 11
Muscle ruptures and hernias Muscle ruptures and hernias have been reported infrequently with pelvic ring injuries. Ryan noted that APC injuries were associated with avulsion of the medial portion of the rectus abdominus muscle, which could give rise to ventral hernias (Ryan, 1971). Ryan also noted an association of direct inguinal hernias with pubic rami fractures occurring after disruption of the posterior wall of the inguinal canal (Ryan, 1971). These are avoided when open reduction/internal fixation is selected for these fractures because the associated soft tissue injuries are repaired at the time of closure. Bowel perforation, bowel entrapment, and bowel herniation also have been documented with comminuted iliac wing fractures (Switzer, 2000). Neurologic injury Approximately 10% of all patients who sustain pelvic fractures also sustain neurologic injury. Most neurologic injuries involve the L5 and S1 nerve roots of the lumbosacral plexus; however, a significant number of patients also can experience sexual dysfunction secondary to nerve injury of the lower sacral nerves (Huittinen, 1972; Weis, 1984). Associated sacral fractures account for many neurologic deficits with pelvic ring injuries. Denis reported a 28% incidence of nerve injury in patients after transforaminal sacral fractures and a 56% incidence of nerve injuries if the central sacrum was fractured (Denis, 1988). Femoral nerve palsies may develop secondary to iliac hematoma and pubic ramus or certain acetabular pattern fracture displacements. Fractures of the pubic ramus at the superolateral aspect of the obturator foramen may cause obturator nerve injury. Lateral femoral cutaneous nerve injuries also may occur as a result of a direct blow to the lateral pelvic region in proximity to the anterior superior iliac spine and fracture displacement of this area. Postoperative wound infection The incidence of postoperative wound infection is low after anterior surgical exposures to the pelvis; however, the incidence increases with indwelling suprapubic catheters, colostomy, or drains in the region of the surgical incisions (Tile, 1995). Posterior surgical exposures are associated with higher instances of postoperative wound infection related to the soft tissue injury, particularly those injuries associated with closed internal degloving injuries (Hak, 1997; Kellam, 1989). Postoperative wound infections after percutaneous fixation techniques are very low, occurring only infrequently (Templeman, Goulet, Duwelius, et al, 1996). Nonunion after a pelvic fracture is uncommon, whereas malunion is more common. Pennal and Massiah evaluated 42 patients with delayed union and nonunion after pelvic fractures. The authors found that the patients who were treated surgically with stabilization and bone grafting demonstrated union in 15 of 16 patients. Nonunions in patients treated nonoperatively did not heal; these patients had poorer outcomes than the surgically treated group (Pennal, Massiah, 1980). Matta et al treated 37 patients with pelvic malunions and nonunions. They highlighted the need for multiple-staged procedures to achieve satisfactory results, which were demonstrated in 32 patients, although 19% of the patients suffered complications (Matta, 1996). Proximal DVTs Proximal DVT have been reported in as many as 61% of pelvic fracture patients without prophylaxis (Geerts, 1994). Magnetic resonance venography has documented a 34% incidence of proximal DVT in patients with acetabular fractures who were treated prophylactically with low dose heparin and mechanical compression devices (Montgomery, 1997). Documentation of proximal DVTs is important because these are most likely to embolize to the lungs. The incidence of pulmonary emboli is 2-12% in patients with pelvic fractures, whereas fatal pulmonary embolism has been reported in 0.5-10% of patients sustaining pelvic fractures (Montgomery, 1997). Detection of proximal DVTs with venography or magnetic resonance venography is expensive and often impractical in the polytraumatized patient; therefore, the most effective treatment of patients with pelvic fractures is adequate prophylaxis. Genitourinary GU complications occur in up to 37% of patients with pelvic ring injuries (Cole, 1996). The most common GU complications occurring with pelvic ring injuries are bladder disruptions and ureteral disruptions, particularly in male patients. Less commonly, the ureters and kidneys may be injured (Watnik, 1996). Dyspareunia and erectile dysfunction occur in approximately 29% of patients with pelvic ring injuries (Cole, 1996; Copeland, 1997). Dyspareunia usually is caused by a displaced ramus fracture, causing pressure on the vaginal vault. Erectile dysfunction can have many causes, including vascular injury, neurologic injury, and psychological stress. A patient with erectile dysfunction should be referred to a urologist for evaluation and treatment. OUTCOME AND PROGNOSISSection 9 of 11
Early stabilization of pelvic ring injuries has demonstrated improved outcomes in patients with pelvic fractures. Stabilization of pelvic fractures immobilizes bleeding cancellous surfaces, thereby decreasing overall blood loss (Huittinen, 1973). Goldstein et al noted decreased operative time, blood transfusions, and hospital stays for patients who were treated within 24 hours of hospital admission (Goldstein, 1986). Similarly, Latenser et al noted decreased complications, blood loss, hospital stays, long-term disability, and better survival for patients treated within 8 hours of hospital admission (Latenser, 1991). Injury pattern and reduction of fracture-related displacements have been correlated with outcome results. Injuries involving the SI joint are associated with poorer results when compared to patients with either sacral fractures or iliac wing fractures (Holdsworth, 1948; Schield, 1991; Tilem, 1988). Posterior pelvic displacement of 5 mm has been identified as leading to poorer patient outcomes (Pohlemann, 1994). Another study noted that pelvic displacement greater than 1 cm in any plane led to increased levels of pain when compared to patients with less than 1 cm of displacement. Limb length discrepancy greater than 2.5 cm also has been implicated in poor results (Tilem, 1988). Permanent neurologic injury contributes to poorer patient outcomes after pelvic ring injury and is present in approximately 20% of patients with unstable pelvic ring injuries (Reilly, 1996; Tile, 1995). Tile noted that permanent nerve damage led to unsatisfactory results in 12 of 248 patients (Tile, 1995). Templeman et al also noted that neurologic injury was associated with compromised outcome in patients with sacral fractures (Templeman, Goulet, Duwelius, et al, 1996). Most neurologic injuries after pelvic ring injuries involve the L5 and S1 nerve roots, although injury may occur along any portion of the lumbosacral trunk. Management of neurologic injuries is expectant, as neurologic recovery has been documented as long as 4 years after injury (Reilly, 1996). FUTURE AND CONTROVERSIESSection 10 of 11
Controversies in treating pelvic fractures revolve around the issue of pelvic stability. Definitions of pelvic stability are vague and hard to quantify in a clinical setting. As a result of a nebulous definition of pelvic stability, determining the type and amount of pelvic stabilization is also controversial. Perhaps Bucholtz and Peters best state the problem (Bucholtz, 1988), as follows: Most clinicians responsible for the care of patients with pelvic ring injuries will base instability on the physical exam. Instability is defined as the inability to resist deformation with physiological loading. The future of pelvic fracture management will likely involve advances in imaging techniques. Except for major pelvic disruptions, the state of the posterior ligamentous structures is inferred from clinical, plain radiographic, and CT scans. Magnetic resonance imaging one day may have a role in visualizing the posterior ligamentous structures, allowing for these injuries to be better defined. Computer-assisted surgery is being developed and studied at various locations. Computer-assisted surgery comprises robotics, image-guided surgical devices, surgical navigation systems, preoperative planners and simulators, and augmented reality or hybrid reality computer interfaces (DiGioia, 1998). Computer-assisted surgery has been used successfully around the pelvis to assist with pelvic osteotomies (Langlotz, 1998). As the technology improves and familiarity grows with these techniques, computer-assisted surgery will likely be used in the management of pelvic fractures. Surgeons should not assume that computer assisted surgery and robotics substitute for their personal knowledge of pelvic injuries and radiographic correlations. The pelvic anatomy, its injury patterns, and their treatments are to date best directed by knowledgeable humans rather than computer software. REFERENCESSection 11 of 11
Article Last Updated: May 18, 2006 |