Internal fixation of an unstable pelvic fracture in a 3-year-old child

Summary A 3-year-old child was trapped under the heavy load of a forklift truck and sustained an unstable pelvic ring fracture (Tile type C) with complete SI disruption, disruption of the pubic symphysis and external rotation injury of the contralateral SI joint. An immediate internal fixation was performed, exposing the SI joint and the pubic symphysis simultaneously. For stabilization an H-plate was used for anterior plate fixation of the SI joint, while the pubic symphysis was stabilized by screws and cerclage wires. After one revision of the symphysis the clinical course was uneventful with anatomical healing of the pelvic ring. The implants were removed after 4 months. Clinical and radiological follow-up after 12 months showed no signs of maldevelopment of the pelvic ring.      

Biomechanical study of 4-hole pubic symphyseal plating: locked versus unlocked constructs

To the authors' knowledge, no published studies have examined the use of locking plates on injuries of the anterior pelvic ring. The purpose of this study was to determine whether locked plates provide enhanced stability in the treatment of pubic symphyseal disruptions. Completely unstable pelvic injuries were simulated in pelvic Sawbones (model 1301; Pacific Research Laboratories, Vashon, Washington) and 2 different fixation constructs used for anterior fixation (4-hole, 3.5-mm pubic symphysis plate with all locked or all unlocked screws). Adjunctive sacroiliac screw fixation with a single 7.3-mm screw placed into S1 was used in all specimens. Specimens were analyzed for motion at the pubic symphysis and sacroiliac joints using a Material Testing System (MTS Systems Corporation, Eden Prairie, Minnesota). Each specimen was subjected to compressive loading in a single-limb stance. Side loading was also examined. The main outcome measurement was motion at the pubic symphysis and sacroiliac joints and overall construct stiffness. No significant difference existed in overall construct stiffness between the 2 methods of pubic symphysis fixation. The motions at the pubic symphysis or injured sacroiliac joints were not significantly different. In addition, motion at the pubic symphysis joint with lateral load was not improved with a locking construct.No significant difference existed between 4-hole locked or unlocked constructs used for fixation of the pubic symphysis. No apparent advantage of locking screws exists for disruptions of the pubic symphysis, and recent reports have questioned the possibility of catastrophic failure.     

Results of internal elastic plate osteosynthesis of simple femoral shaft fractures in polytraumatized patients. An alternative procedure

Summary Primary medullary nailing of femoral fractures is burdened by the risk of central and pulmonary complications in patients with polytrauma, especially in conjunction with craniocerebral or thoracic trauma. This also applies to unreamed medullary nailing. Primary treatment with external fixation necessitates secondary surgery with an altered procedure, the timing of which is not predictable. Plate osteosynthesis with anatomical repositioning of the fragments and rigid fixation is a technically demanding procedure, but can lead to fragment necrosis due to fragment denudation. In a prospective study conducted from 1 September 1994 to 30 June 1996 on 17 polytraumatized patients (average ISS: 30 points), simple femoral stem fractures (A-1 to B-3 of the AO-classification) were stabilized by elastic plate osteosynthesis using biological technique. While cautiously preserving the periosteal and muscle connections to the bone, a plate is inserted as a bridge without any interfragmentary compression. At least two to four holes are left free in the center of the plate. This allows micro-movements in the fracture gap without the risk of material fatigue. All of the fractures were immediately stabilized on the day of the accident. In four patients with severe craniocerebral trauma or manifest shock, the procedure was changed to plate osteosynthesis after application of primary external fixation. Secondary injuries (joint and pelvic fractures or craniocerebral trauma) delayed early loading in 12 cases. Four patients were mobilized postoperatively under partial loading. A fixation callus was radiologically detectable on average 6 weeks after surgery. This often allowed additional loading, depending on the secondary injuries. Full loading was possible after 14 weeks. Complications included one case of surgery-related malpositioning, one soft-tissue infection, one case of plate detachment after a fall and one case of periosseous calcification. There were no cases of bone infections or pseudoarthroses. Elastic plate osteosynthesis is thus a conservative osteosynthesis procedure with a low complication rate in polytraumatized patients, even in those with simple femoral fractures.      

A biomechanical cadaver comparison of suture button fixation to plate fixation for pubic symphysis diastasis

ObjectivesTo determine whether suture button fixation of the pubic symphysis is biomechanically similar to plate fixation in the treatment of partially stable pelvic ring injuries.MethodsTwelve pelvis specimens were harvested from fresh frozen cadavers. Dual-x-ray-absorptiometry (DXA) scans were obtained for all specimens. The pubic symphysis of each specimen was sectioned to simulate a partially stable pelvic ring injury. Six of the pelvises were instrumented using a 6 hole, 3.5 mm low profile pelvis plate and six of the pelvises were instrumented with two suture button devices. Biomechanical testing was performed on a pneumatic testing apparatus in a manner that simulates vertical stance. Displacement measurements of the superior, middle, and inferior pubic symphysis were obtained prior to loading, after an initial 440 N load, and after 30,000 and 60,000 rounds of cyclic loading. Statistical analysis was performed using Wilcoxon-Mann-Whitney tests, Fisher’s exact test, and Cohen’s d to calculate effect size. Significance was set at p < 0.05.ResultsThere was no difference between groups for DXA T scores (p = 0.749). Between group differences in clinical load to failure (p = 0.65) and ultimate load to failure (p = 0.52) were not statistically significant. For symphysis displacement, the change in fixation strength and displacement with progressive cyclic loading was not significant when comparing fixation types (superior: p = 0.174; middle: p = 0.382; inferior: p = 0.120).ConclusionSuture button fixation of the pubic symphysis is biomechanically similar to plate fixation in the management of partially stable pelvic ring injuries.     

创伤性耻骨联合分离合并骶髂复合体损伤的手术治疗

目的:探讨创伤性耻骨联合分离合并骶髂复合体损伤适应证、手术方法及疗效。方法:2002年3月-2004年6月,对20例创伤性耻骨联合分离合并骶髂复合体损伤患者,采用前路切开复位重建钢板内固定治疗耻骨联合分离和后路在CT引导下经皮空心拉力螺钉固定治疗骶髂复合体损伤。男12例,女8例;年龄18～65岁,平均42.6岁。通过影像学检查明确20例患者有34侧骨盆骶髂复合体损伤。按照AO骨盆环损伤方法分型:B型8例,其中B2型5例,B3型3例;C型12例,其中C1型4例,C2型5例,C3型3例。结果:20例均获随访,随访时间4～21个月,平均14.2个月。平均入院后第8天手术。前路手术时间平均150min,后路手术时间平均60min。前路术中平均失血200ml,后路术中平均失血30ml。20例共置入骶髂螺钉34枚。术后3周患者可扶双拐下地行走,3～4个月可完全负重行走,并逐渐恢复体力劳动。未发生神经损伤及螺钉断裂现象。耻骨联合分离患者术后影像学显示解剖学形态完全恢复,耻骨联合间隙<2cm。结论:前环耻骨联合分离时要考虑可能有后环骶髂复合体损伤存在。耻骨联合分离与骶髂关节损伤应分别根据具体情况采用相应的固定术式。     

Anterior pelvic ring fractures: a proposal of a variant of osteosynthesis of the pubic symphysis

Different internal fixation techniques (ORIF) have been proposed for the reduction and stabilization of traumatic diastase of the pubic symphysis: two-hole plates, multi-hole plates and double plates. Classically the synthesis of the symphysis is executed with 2 plates of 3.5 or 4.5 mm (anterior and sovrapubic), where screws are inserted from anterior to posterior. Since 2005 to January 2008, the first author has treated 16 patients modifying the anterior screws positioning for the stabilization of the pubic symphysis. In the 16 considered cases we have positioned just 2 anterior screws, one for each pubic branch, in the conviction of a better respect of the physiological forces lines. All the screws have a length from 55 to 65 mm. Functional results were excellent in 90%, good in 10%; reductions resulted excellent in 90% and good in 10%. The modified screws fixation method could be proposed in the management of treatment of anterior unstable pelvic ring.     

Can locking plate fixation of symphyseal disruptions allow early weight bearing?

IntroductionAnterior pubic symphyseal plate fixation is the recommended treatment for disruption of pubic symphysis in an unstable pelvic ring injury. The rigid construct offered by locking symphyseal plate has the theoretical advantage of allowing patients to weight bear early. However, there are concerns of catastrophic failure about the locked plate construct. The purpose of the study was to establish if locking plate fixation for pubic symphysis disruption was effective to allow patients to mobilise weight bearing immediately after surgery.Patient and MethodsRetrospective analysis of a prospectively collected database from a single centre was performed. The study period was from 2008 to 2017. Radiographic evidence of fixation failure, revision surgery, removal of metalwork and follow up duration was noted.ResultsWe identified 46 patients (F:M 8:38) with a mean age of 46 years (range 14 to 74 years). Based on the mechanism of injury patients were classified into Antero-posterior compression (28), Vertical shear [10], lateral compression [4] and combined mechanism [4]. Either a 4-hole or 6-hole locking plate was used in all patients, depending on fracture extension. Posterior fixation was required in 28 (61%) patients. All patients were allowed to fully or partial weight bear. The mean radiological follow-up period was 31 weeks with 13 (28%) patients having evidence of radiological failure. Revision was performed in 1 (2%) patient, in whom the screws had pulled out of the bone. The most common mode of failure was either the screw backing out from the plate or broken screw. Among the 4 (8%) patients who had their metalwork removed, 1 (2%) had delayed onset of infection, 2 (4%) had symptoms related to backed out screw and 1 (2%) opted electively to have metalwork removed.ConclusionsWith our series of patients, we have found that using locking plate for pubic symphyseal diastasis is safe and effective in allowing patients to weight bear early. A low complication rate and need for re-operation is demonstrated.     

Triangular osteosynthesis and iliosacral screw fixation for unstable sacral fractures: a cadaveric and biomechanical evaluation under cyclic loads

OBJECTIVE: To conduct a biomechanical comparison of a new triangular osteosynthesis and the standard iliosacral screw osteosynthesis for unstable transforaminal sacral fractures in the immediate postoperative situation as well as in the early postoperative weight-bearing period. DESIGN: Twelve preserved human cadaveric lumbopelvic specimens were cyclicly tested in a single-limb-stance model. A transforaminal sacral fracture combined with ipsilateral superior and inferior pubic rami fractures were created and stabilized. Loads simulating muscle forces and body weight were applied. Fracture site displacement in three dimensions was evaluated using an electromagnetic motion sensor system. INTERVENTION: Specimens were randomly assigned to either an iliosacral and superior pubic ramus screw fixation or to a triangular osteosynthesis consisting of lumbopelvic stabilization (between L5 pedicle and posterior ilium) combined with iliosacral and superior pubic ramus screw fixation. MAIN OUTCOME MEASURES: Peak loaded displacement at the fracture site was measured for assessment of initial stability. Macroscopic fracture behavior through 10,000 cycles of loading, simulating the early postoperative weight-bearing period, was classified into type 1 with minimal motion at the fracture site, type 2 with complete displacement of the inferior pubic ramus, or type 3 with catastrophic failure. RESULTS: The triangular osteosynthesis had a statistically significantly smaller displacement under initial peak loads (mean +/- standard deviation [SD], 0.163 +/- 0.073 cm) and therefore greater initial stability than specimens with the standard iliosacral screw fixation (mean +/- SD, 0.611 +/- 0.453 cm) ( = 0.0104), independent of specimen age or sex. All specimens with the triangular osteosynthesis demonstrated type 1 fracture behavior, whereas iliosacral screw fixation resulted in one type 1, two type 2, and three type 3 fracture behaviors before or at 10,000 cycles of loading. CONCLUSION: Triangular osteosynthesis for unstable transforaminal sacral fractures provides significantly greater stability than iliosacral screw fixation under in vitro cyclic loading conditions. In vitro cyclic loading, as a limited simulation of early stages of patient mobilization in the postoperative period, allows for a time-dependent evaluation of any fracture fixation system.     

Improvement of external fixator performance in type C pelvic ring injuries by plating of the pubic symphysis: an experimental study on 12 external fixators

BACKGROUND: In an earlier study, we introduced a pelvic ring stability criterion for weightbearing stabilization. In a loading test, however, current external fixation systems alone did not meet this criterion. Internal fixation of the dorsal ring can significantly increase stability, but the condition of severely injured patients is often a contraindication for major surgery. The aim of this study is to optimize external pelvic ring fixation without dorsal ring stabilization to allow weightbearing in early mobilization of patients with unstable pelvic ring injuries. METHODS: The stiffness of external fixation systems alone and in combination with one or two anterior plates was measured by using a pelvic replica with a type C pelvic ring injury. Endpoints were 15 mm of dislocation or tolerance of 560 N. RESULTS: Addition of one plate at least doubles stiffness, whereas two-plate fixation results in at least a fourfold stiffer configuration. Frame configurations profit more than single-bar systems, and all but one system resist the weightbearing load after double-plating of the pubic symphysis. CONCLUSION: The choice of double-plate fixation of the anterior ring in addition to external fixation results in weightbearing capacity.     

Biomechanical testing of a concept of posterior pelvic reconstruction in rotationally and vertically unstable fractures

The purpose of this study was to assess the stability of a developmental pelvic reconstruction system which extends the concept of triangular osteosynthesis with fixation anterior to the lumbosacral pivot point. An unstable Tile type-C fracture, associated with a sacral transforaminal fracture, was created in synthetic pelves. The new concept was compared with three other constructs, including bilateral iliosacral screws, a tension band plate and a combined plate with screws. The pubic symphysis was plated in all cases. The pelvic ring was loaded to simulate single-stance posture in a cyclical manner until failure, defined as a displacement of 2 mm or 2°. The screws were the weakest construct, failing with a load of 50 N after 400 cycles, with maximal translation in the craniocaudal axis of 12 mm. A tension band plate resisted greater load but failure occurred at 100 N, with maximal rotational displacement around the mediolateral axis of 2.3°. The combination of a plate and screws led to an improvement in stability at the 100 N load level, but rotational failure still occurred around the mediolateral axis. The pelvic reconstruction system was the most stable construct, with a maximal displacement of 2.1° of rotation around the mediolateral axis at a load of 500 N.     

Screw osteosynthesis of displaced fractures of the radial condyle of the humerus in childhood. A long-term prospective study

Summary Pseudoarthrosis and cubitus valgus as main complications following displaced fractures of the radial condyle in children can be prevented by open reduction and fixation by K wires. However, delayed union and stimulation of the radial physis with condylar overgrowth and varisation of the elbow as well as fishtail deformities of the distal end of the humerus are reported nevertheless. To prevent those growth disturbances all primary and secondary (4-day X-ray control) displaced fractures of the radial condyle, i. e. those with a central gap of more than 2 mm, were prospectively treated by open reduction and osteosynthesis with a metaphyseal lag screw beginning 1974. Sixty-six patients (41 boys, 25 girls) with an average follow-up of 10 years (2–22 years) sustained 28 primary and 6 secondary displaced fractures. In 5 cases a K wire fixation was performed in view of the smallness of the fragment. Two children with conservative treatment following overlooked displaced fractures showed condylar overgrowth and varisation of the elbow. Screw osteosynthesis led to symmetric elbow angles and function in all cases, whereas fishtail deformities could be observed in 8 of 27 children, probably as a consequence of the remaining central fracture instability. Conclusion: Open reduction and osteosynthesis with a metaphyseal lag screw prevents condylar overgrowth in displaced fractures of the radial condyle by guaranteeing fracture healing in anatomic position within 3–4 weeks. However, fishtail deformity can not be prevented by metaphyseal compression only.      

重建钢板内固定治疗耻骨联合分离

目的探讨重建钢板内固定治疗耻骨联合分离的效果.方法开放复位重建钢板内固定治疗19例耻骨联合分离患者.结果19例均恢复骨盆的完整性和稳定性.随访时间6～24个月,平均12个月,患者均恢复日常工作和生活.结论重建钢板内固定治疗耻骨联合分离是一种较理想的方法.     

Spinopelvic injuries. Facts and controversies

Spinopelvic injuries result from high energy trauma with overloading through the sacrum. These lesions can accomplish either bone fractures, ligament injuries or, most commonly, both. They may be accompanied with other associated life threatening injuries and cause biomechanical instability with potential fracture non-union, mal-union and subsequent lifetime pain and disability. Surgical stabilization of spinopelvic injuries requires planning in order to apply the appropriate osteosynthesis principles (compression; neutralization; buttressing and tension band).In general terms simple sacral fractures can be treated under compression by iliosacral screws. However, as more complex ones cannot be compressed, they need vertical support and neutralization of shearing forces (neutralization and buttressing principles). For that purpose, spinopelvic instrumentations appear to be the current appropriate technique of stabilization. In the herein paper the general principles of sacral fracture osteosynthesis are discussed, as well as its application to spinopelvic injuries. Controversies on positioning, surgical approach, per-operative traction, sacral laminectomy, type of biomechanical construct, length of fixation, screws length, mode of weight bearing, and osteosynthesis hardware removal are discussed.     

A biomechanical in-vitro study on an alternative fixation technique of the pubic symphysis for open book injuries of the pelvis

PurposeImplant failure rates remain high after plate fixation in pelvic ring injuries. The aim of this study was to compare an alternative fixation technique with suture-button devices and anterior plate fixation in partially stable open-book injuries.Material and MethodsWe acquired 16 human fresh frozen anatomic pelvic specimens. The sacrospinous, sacrotuberous, and anterior sacroiliac ligaments were bilaterally released, and the pubic symphysis transected to simulate a partially stable open-book (AO/OTA 61-B3.1) injury. The specimens were randomly assigned to the two fixation groups. In the first group two suture-button devices were placed in a criss-crossed position through the symphysis. In second group a six-hole plate with standard 3.5 unlocked bicortical screws was used for fixation. Biomechanical testing was performed on a servo-hydraulic apparatus simulating bilateral stance, as described by Hearn and Varga. Cyclic compression loading with a progressively increasing peak load (0.5 N/cycle) was applied until failure. The failure mode, the load and the number of cycles at failure and the proximal and distal distance of the symphysis during testing were compared.ResultsThere was no implant failure in either of the two groups. Failures occurred in nine pelvises (56.2%) at the fixation between the sacrum and the mounting jig and in seven pelvises (43.8%) in the sacroiliac joint. Neither the ultimate load nor the number of cycles at failure differed between the surgical techniques (p = 0.772; p = 0.788, respectively). In the suture button group the mean ultimate load was 874.5 N and the number of cycles at failure was 1907.9. In the plate group values were 826.1 N and 1805.6 cycles, respectively. No significant differences at proximal and distal diastasis of the symphysis were monitored during the whole loading process.ConclusionThe fixation with suture button implants showed comparable results to anterior plate fixation in open-book injuries of the pelvis.     

Complete rupture of the urethra in combination with anterior pelvic fracture and symphyseal rupture after spontaneous vaginal delivery

Summary We report on a complete longitudinal rupture of the urethra in combination with a rupture of the pubic symphysis and pelvic fracture during spontaneous vaginal delivery. Only after stabilisation of the pelvic fracture by external skeletal fixation adaptation of the urethra was possible. Three weeks later after removing of the transurethral catheter a mild stress incontinence could be observed. In the follow up one year later the patient was completely continent. The cosmetic result was satisfactory. There was no cystocele. An unclear haematuria after delivery needs a meticulous urological examination. Early repair of urethral disruption minimize the risk of severe incontinence. Coordinated care between the trauma surgeon and urologist is required for successful treatment of this rare combined injury after birth.      

经皮闭合内固定治疗骨盆环损伤

目的对骨盆环损伤闭合内固定术的临床疗效进行评价。方法回顾性分析58例骨盆环损伤患者的临床资料。其中女24例,男34例,年龄18—62岁,平均年龄36岁。全部患者均采用骶髂关节螺钉、耻骨螺钉、耻骨联合螺钉及髂骨后部螺钉等多种形式的闭合内固定。结果58例中满意复位者52例,6例复位不满意;57例骨折愈合,1例骨不连接;56例无血管神经损伤,2例有S1神经损伤,遗留下肢及马鞍麻木。结论经皮闭合固定骨盆环损伤小、出血少、固定效果较好,是一种有前景的手术方式,但对操作者要求高。术前大重量骨牵引有利于术中复位。     

Comparative fatigue strengths and stabilities of metacarpal internal fixation techniques

To study quantitative differences in the fatigue strength and stability obtained with 5 types of internal fixation of metacarpal fractures, 105 preserved human metacarpals were cyclically tested in bending, torsion, and axial loading after oblique osteotomies of the metacarpal and internal fixation. The dorsal plate with lag screw was superior in all modes, followed by the two dorsal lag screws, crossed Kirschner wire tension banding, and intramedullary Kirschner wire fixation. The five intramedullary and the paired intramedullary Kirschner wire fixations were not statistically different. The fatigue life of the plate fixation was significantly larger in bending (1.5 times), torsion (1.6 times), and axial loading (2.5 times) than the second strongest fixation, two dorsal lag screws. Its initial rigidity was significantly higher in axial loading (1.5 times) but was not statistically different in bending and torsion.     

The native tensile strength of the supraspinatus tendon. A biomechanical study

Summary The traumatic tear of the rotator cuff has been discussed very intensively for a long time despite the fact that there do not exist representative objective data about the native tensile strength of these tendons. The aim of this study was to evaluate the age related native strength of the supraspinatus tendon. 25 fresh frozen cadaver specimen (age: 23–94, 24 h post mortem, 18 male, 7 female) were tested using so called cryo-jaws for soft tissue fixation. The results showed the major part of the tensile forces to be transmitted through the anterior thicker part of the tendon (e. g. 14 bony avulsions in this area). We found significant correlations between age and maximum strength (p < 0.001), age and stiffness of the tendon (p < 0.005) and stiffness and maximum strength (p < 0.001). These results show that tensile strength and stiffness of the supraspinatus tendon decrease with age. However, a 65 year old specimen still demonstrates a weight bearing structure (about 900 N maximum tensile strength) and is not necessarily ruptured or degeneratively altered.      

Fractures of the neck of the femur in children

Summary In a retrospecitve multicenter study we followed-up 30 fractures of the neck of the femur in children aged 11 years (1.5–15 years) for 4.8 years (0.5–20.0 years). It is the aim of this study to analyse factors possibly related to outcome, like age at injury, type of fracture, interval between injury and treatment, method of stabilization and postoperative interval until full weight bearing. At follow-up subjective parameters (pain, weather sensitiveness), clinical parameters (range of motion, claudication, leg length discrepancies) and radiological parameters (hip series) were investigated and medical charts and roentgenograms were reviewed using a standardized protocol. 29 of 30 children (96.7 %) have sustained displaced fractures. Non-operative treatment has been applied in 4 children. 26 femoral neck fractures (type I: 1, type II: 8, type III: 17) were stabilized by internal fixation using screws and/or pins. Following non-operative treatment one child suffered a coxa vara and another child suffered a avascular femoral head necrosis in combination with coxa vara and leg length shortening of 4 cm. Following operative treatment 9 of 26 children (34.6 %) sufferred a avascular femoral head necrosis and 3 children (11.5 %) suffered a coxa vara. In 6 of 26 children (23 %) we observed leg length discrepancies > 2 cm. We were not able to demonstrate any significant follow-up result differencies between the groups of children who have sustained type II or type III fractures, or between the groups of children aged < 10 years when compared to children aged > 10 years, or between the group of children who were operated on within 6 hours after the accident when compared to the group of children operated > 6 hours after the accident. We observed no significant follow-up result differences between the groups of children who had different intervals between operation and full weight bearing. Operative fracture management remains the treatment of choice in the majority of displaced femoral neck fractures in children. However, in our limited study we were not able to demonstrate any significant follow-up result differences between the group of children treated by immediate open reduction and internal fixation (interval injury – operation < 6 hours) when compared to children who had been operated > 6 hours after the injury.      

Treatment of intra-articular fractures of Os calcis with open reduction,internal fixation and bone graft

Surgical Principles The subtalar joint is a major weight bearing joint in the lower limb. Displaced intra-articular fractures of the os calcis should be treated with anatomical reduction and stable internal fixation to allow early mobilization. Intra-articular fractures of the os calcis lead to loss of joint congruity, and impaction of the cancellous bone. Bone grafting, together with stable internal fixation, allow early mobilization and weight bearing after surgery. The operation is done with the lateral approach which allows direct access to the fracture site. The subchondral bone, the sustentaculum tali and the medio-inferior part of the os calcis provide good bone stock for the purchase of screws. After reduction and fixation of the depressed fragments, the space is filled with cortico-cancellous grafts. The lateral wall of the os calcis is buttressed with a plate. Postoperatively, passive mobilization is started early, walking with a weight relieving calliper lasts for the first six weeks and graduated weight bearing is started on the seventh week.