1. Pelvic Ring Injuries Definitive Treatment
Steven A. Olson, MD
Rafael Neiman, MD Created March 2004 Revised 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 the inability 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 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 > 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, pp , 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 Pubic Ramus Fractures
Rarely repaired in Bucholz type II fractures
Matta series-over 84 percent treated nonoperatively, even in unstable injuries treated posteriorly (Bucholz III or Tile C)

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 require operative 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, p

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 Disadvantages
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

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

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

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

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

55. Complications of Treatment
Infection
Neurologic Injury
Loss of reduction

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

71. Acknowledgment
Pelvic Ring Injuries can be devastating, but with prompt and thoughtful care, outcomes have been shown to improve.
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