Iliosacral Screw “Safe Zone”

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Presentation transcript:

Iliosacral Screws: Radiographs & Anatomy 4/21/2017 5:56 PM Iliosacral Screws: Radiographs & Anatomy V4

Iliosacral Screw “Safe Zone” Sacral Ala (L5) S1 Foramen Upper Sacral Nerve Root Tunnel (S1) Spinal Canal (cauda) From Posterior Pelvic-Ring Disruptions: Iliosacral Screws, M.L Chip Routt, Jr. M.D. and Peter T. Simonian, M.D. in Master Techniques in Orthopaedic Surgery: Fractures. Lippincott Williams & Wilkins, 1998.

Imaging All patients have different anatomy Varying amounts of lordosis Varying sacral slope Views determined by anatomy Not textbook (40-40)

Inlet Radiograph Superimposed S1 And S2 Bodies (Inlet)

Spinal Canal Wollinsky & Lee, JOT 2007

Outlet Radiograph Sacral Foramina En Face; S2 ~ superior rami

Sacral Ala = 3D structure; Inlet/Outlet insufficient to r/o breach From Posterior Pelvic-Ring Disruptions: Iliosacral Screws, M.L Chip Routt, Jr. M.D. and Peter T. Simonian, M.D. in Master Techniques in Orthopaedic Surgery: Fractures. Lippincott Williams & Wilkins, 1998.

Perfect Lateral of Sacrum Need REDUCED pelvis! Superimposition Of AICD or Greater Notches Parallax makes both difficult Farrell JOT 2009

Farrell JOT 2009

Traction & Fluoroscopy Set Up Anterior/Caudad Traction Vector Appropriate For Most Fracture Displacements From Posterior Pelvic-Ring Disruptions: Iliosacral Screws, M.L Chip Routt, Jr. M.D. and Peter T. Simonian, M.D. in Master Techniques in Orthopaedic Surgery: Fractures. Lippincott Williams & Wilkins, 1998.

Iliosacral Screw Inlet (Anterior / Posterior) Make Translations / Rotation In Relation To Beam (Perpendicular)

Iliosacral Screw Outlet (Cephalad / Caudad) Make Translations / Rotation In Relation To Beam (Perpendicular)

***Inlet-Outlet Orthogonal ??*** Not always

Iliosacral Screw Placement: Case 1 30 year old Hispanic male Fall from scaffolding Injury films obtained in binder Hemodynamically unstable Bladder injury

Iliosacral Screw Placement: Case 1 Immediate concerns? Unstable pelvic ring with hemodynamic instability Binder vs ex-fix Angiography?

Iliosacral Screw Placement: Case 1 Converted from binder to external fixator Anterior ring injury more apparent out of binder Bladder neck injury treated with foley catheter Pelvic angiography

Iliosacral Screw Placement: Case 1 Definitive treatment?

Iliosacral Screw Placement: Case 1 Planned open reduction of anterior sacrum and SI joint IS screw fixation of central fracture Continued external fixation of anterior ring injury Issues?

Iliosacral Screw Placement: Case 1 Anterior sacral fragment and SI joint reduced Central sacral fracture badly malreduced IS screw a little anterior

Iliosacral Screw Placement: Case 1 Solution? Anterior sacral ORIF revised ORIF of symphysis performed Bladder injury repaired Improved central sacral reduction IS screw removed Postop CT to assess reduction

Iliosacral Screw Placement: Case 1

Iliosacral Screw Placement: Case 1