The role of computerized tomographic scanning in the evaluation of major pelvic fractures

Twenty-five patients with double vertical fractures of the pelvic ring had evaluations by both plain radiography and computed-tomography scanning of the pelvis. In eight of the twenty-five patients, the interpretation that was made from the plain radiographs, based on the classification of Pennal et al., changed when additional anatomical information was provided by the computed-tomography scan. We recommend that computed tomography be used for: (1) double vertical fracture-dislocations of the pelvic ring in which plain radiographs are inadequate to judge pelvic stability, (2) fractures of the pelvic ring with extension into the acetabulum, and (3) major injuries to the hemipelvis that are to be treated by open reduction and internal fixation. However, due to the increased cost and radiation exposure, routine computed-tomography scanning is not justified for all injuries to the pelvic ring.     

Similar patient reported outcomes at long-term follow-up after external fixation versus internal fixation of the anterior ring component of APC injuries

Purpose: Unstable pelvic ring injuries produced by external rotation of the hemipelvis and a symphyseal disruption are most often treated with internal fixation of the anterior ring, with percutaneous treatment of the posterior ring as needed. In some clinical situations, patients are treated with external fixation for their anterior injuries and the long-term functional outcomes associated with external fixation are not well understood. We ask if there is a difference in functional outcome, between treatment of these injuries with internal versus external fixation, when measured at a minimum of three years after injury.Method: This was a retrospective cohort study performed at a level one regional trauma center. Trauma database review identified 128 patients, with 70 subsequently excluded, with unstable anterior posterior compression (APC) pelvic ring injuries (OTA 61B2.3 & 61C1.2) treated with surgery with minimum three years of follow-up. An intervention of internal fixation versus external fixation of anterior pelvic ring was performed, and depending on the injury, supplemented with posterior iliosacral screw fixation. Main outcome was measured with the Majeed functional outcome score (0-100).Results: Patients treated with external fixation reported a Majeed score of 70 (95% CI 28-100) compared to 79 (95% CI 36-100) in those with internal fixation (p-value 0.28). Subgroups of the Majeed score were not significantly different (p value > 0.05). Open fractures, severity of injury, and ISS were worse in those treated with external fixation. There was no differential loss to follow-up.Conclusion Patients with unstable pelvic ring injuries with symphyseal disruptions treated with external fixation as definitive treatment versus internal fixation may fare no different in the long term.     

The floating hip injury: which should we fix first?

In floating hip injuries, the priority of the steps in fixation has not been well described. We have treated these patients in accordance with the following protocols. In patients with pelvic ring fractures, the external fixation should be performed first, and in patients with acetabular fractures, the femoral fractures should be internally fixated first. The purpose of the present study was to review our experience with these fracture treatments to evaluate our strategy. For 8 years, 31 patients with femoral fractures associated with ipsilateral fractures: 26 unstable pelvic ring fractures and 7 unstable acetabular fractures were surgically treated at our level 1 trauma center. We reviewed the admission, operation, and follow-up records retrospectively and evaluated the order of the fixation and the complications. Two patients with acetabular fractures failed to follow our protocol outlined at the preoperative planning stage. There were no surgical difficulties other than two patients with the hemipelvis dislocated proximally who required traction of the fixated femur. The complications that were thought to be related to our protocol were one fat embolism syndrome and one pubic fracture displacement. One heterotopic ossification seemed to occur due to using a single approach for both fractures. We believe our protocol to be generally effective, however, in patients with acetabular and vertical shear type pelvic ring fractures, the internal or external fixation of the femur should be performed before the internal fixation of the pelvis.     

Operative interne Stabilisierung von Beckenringfrakturen in Abhängigkeit von der Klassifikation

There has been a significant change in the treatment of the disrupted pelvic ring in the last few decades. Nonoperative treatment of disrupted pelvic ring fractures often led to unsatisfactory results (patients were treated with slings and traction) such as malrotation of the hemipelvis, malunion or nonunion, pain, neurologic dysfunction, or genitourinary dysfunction. The therapeutic approach shifted to widely accepted standards of internal fixation based on the general format of the AO group or the often-used Tile classification. The concept of operative treatment of the disrupted pelvic ring is based on correct anatomical reduction and partial or half weight bearing of the pelvic ring after internal fixation. Only internal fixation allows the early mobilization of the patient and reduces the rate of major chronic disabilities (malrotation, malunion or nonunion, pain, neurologic dysfunction, or genitourinary dysfunction).     

Posterior locked lateral compression injury of the pelvis: report of three cases

Lateral compression injuries to the pelvis typically result in a rotationally unstable and vertically stable condition including an impaction and compression fracture of the posterior pelvic ring. The operative and postoperative management, as well as the morbidity and mortality, of these fractures differs significantly from vertical shear injuries to the pelvis, which are characterized by vertical and rotational instability. We report on three unusual lateral compression injuries to the pelvis, resulting in a complete disruption of the pelvic ring with vertical and rotational instability, by definition. Nevertheless, in these patients, locking of the posterior pelvic ring with medial translation of the iliac wing anterior to the sacrum resulted in a pseudostable condition. Their high rate of fracture-related associated injuries and possible complications, as well as the malalignment of the pelvis, required surgical restoration of the pelvic ring. Fracture reduction was successfully performed through an anterior approach in one patient and a posterior approach in two patients; the posterior approach was preferred. Open reduction and internal fixation of these pelvic ring fractures can result in a satisfactory outcome if the associated injuries are successfully dealt with.     

骨盆新月形骨折的研究进展

骨盆新月形骨折是Young-Burgess骨盆骨折分型中侧方挤压型Ⅱ型中典型的后环损伤表现。近年来许多学者就其受伤机制、影像学表现、分型、骨盆稳定性及手术方式提出了一些新的观点。微创复位经皮螺钉内固定在骨盆新月形骨折的治疗中应用越来越广泛。本文就骨盆新月形骨折的临床特征、分型、治疗等方面作一综述,以期使读者对骨盆新月形骨折有一个更加全面的认识,从而选择更合理的治疗方式。     

Triangular Osteosynthesis for Unstable Sacral Fractures

Objective Stable internal fixation of sacral fractures after anatomic reduction of the vertical displacement. Decompression of nerve roots. Early return to pain-free function. Indications All vertically unstable sacral fractures of type C pelvic ring disruptions. Sacroiliac dislocations. Contraindications Compound fractures. Soft tissue detachment of posterior pelvic ring or fractures associated with considerable soft tissue trauma constitute a contraindication limited to the immediate post-injury phase given the rist of infection and soft tissue complications. Surgical Technique Curvilinear or paravertebral posterior approach. Reduction of the fracture, stabilization between pedicle of L4 or L5 and posterior aspect of the iliac bone or the sacral wing lateral to the sacral fracture. Thereafter, iliosacral screw fixation (unilateral fractures with little displacement) or transsacral plate fixation (bilateral fractures or unilateral fractures with marked displacement). If a stabilization of the anterior pelvic ring has been performed, 1 iliosacral screw is sufficient, otherwise 2 screws should be used. Stabilization of the anterior pelvic ring is only indicated in the presence of disruption of the symphysis, marked displacement of fragments, or if associated injuries necessitate an anterior approach. Results Since April 1992, vertically unstable sacral fractures were treated with this stabilization in 48 patients (average age 34 years, range 15 to 72 years). Since 1994, the start of postoperative full weight-bearing was gradually advanced. Despite the immediate postoperative full weight-bearing, a loss of reduction was not observed in properly performed triangular internal fixation. An incomplete reduction associated with an inadequate stabilization led to a loss of correction in 3 patients. Prominent heads of pedicle screws at the level of the posterior iliac crest may cause soft tissue problems. All fractures consolidated. Implant removal was performed in 23 patients, in 1 patient on accound of deep infection and in 22 after consolidation of the fracture. Out of 25 patients with preoperative neurologic deficit, 4 showed a complete and 3 a partial recovery.     

切开复位内固定治疗垂直不稳定骨盆骨折

目的探讨切开复位内固定治疗垂直不稳定骨盆骨折的临床疗效。方法28例垂直不稳定骨盆骨折患者在大重量牵引纠正垂直移位后,全部行切开复位内固定,骨盆前环骨折均用重建钢板内固定。结果随访12~48个月,平均23.2个月,均骨性愈合,无下肢不等长,骨盆畸形基本纠正,按刘利民等功能评定标准,优10例,良13例,可5例。结论切开复位内固定治疗垂直不稳定骨盆骨折可取得满意疗效,对前后环骨盆骨折尽可能手术固定。     

有限切开内固定结合外固定器治疗Tile C型骨盆骨折

目的 探讨有限切开内固定结合外固定器治疗Tile C型骨盆骨折的临床价值.方法 采用有限切开内固定结合外固定器治疗Tile C型骨盆骨折28例,男17例,女11例;年龄21~52岁,平均34岁;合并神经损伤4例,失血性休克16例,其他部位骨折15例.按照Tile分型均为C型骨折,C1型15例,C2型9例,C3型4例.结果 28例中,23例复位满意,5例未完全复位,其中3例纵向移位≥1cm,2例横向分离移位(耻骨联合分离≥2cm,耻骨支分离≥1cm).骨折愈合时间2~5个月,平均3.2个月.2例切开复位后骶髂部皮肤发生浅层感染,培养为表皮葡萄球菌,选用敏感抗生素治疗后感染得到控制.3例外固定针孔感染.1例骶髂螺钉固定术后CT证实螺钉穿出S1A椎体前皮质.1例外固定支架固定螺钉穿出髂嵴外侧皮质.1例术后股外侧皮神经损伤.26例获得随访,随访时间18~58个月,平均48个月.根据Majeed制定评估标准,优17例,良7例,可2例,优良率92.3%.4例术前有神经损伤症状者,2例在术后4个月时完全恢复,2例未恢复.4例患者主诉腰骶部疼痛.结论 有限切开内固定可纠正不稳定骨盆骨折纵向移位,而横向移位可以使用外固定器复位固定.     

Fixation of posterior pelvic ring disruptions through a posterior approach

Objective  Stable internal screw fixation of posterior pelvic ring disruptions through a posterior approach. Indications  Complete, unstable sacroiliac dislocations with incompetence of anterior and posterior sacroiliac ligaments. Sacroiliac fracture dislocations. Displaced vertical sacral fractures. Contraindications  Damage to posterior soft tissues. Acceptable closed reduction of sacrum or sacroiliac joint. Ipsilateral acetabular fractures treated through an anterior approach. Inadequate intraoperative fluoroscopic visualization of posterior pelvis. Surgical Technique  Vertical paramedian incision overlying the sacroiliac joint. Release of origin of gluteus maximus. Inspection and reduction of sacroiliac joint. Stabilization with iliosacral screws under image intensification. Secure repair of gluteal fascia. Results  107 patients with unstable pelvic ring fractures were treated with open reduction and internal fixation of which 83 had an open reduction of posterior ring injuries. Accuracy of reduction: more than 95% of patients had residual displacement of less than 10 mm. Two patients had a deep wound infection postoperatively. Two-thirds of the patients were able to resume their previous occupation. Pain was either absent or occurred only with strenuous activities. 63% had a normal gait.     

垂直不稳定骨盆骨折内固定垂直稳定性的生物力学研究

目的探讨垂直不稳定骨盆骨折空心螺钉和钢板内固定前后环或后环的垂直方向稳定性差异。方法：将6具尸体骨盆随机取3具做压力测试为正常组，然后制成垂直不稳定骨盆骨折模型，分别行后环空心螺钉结合前环空心钉、后环空心螺钉、后环结合前环钢板、后环钢板内固定。结果在垂直方向，后环空心螺钉内固定强于钢板螺丝钉内固定，增加前环内固定可以显著增加前环的稳定性。结论垂直不稳定骨盆骨折空心螺钉内固定具有较好的生物力学稳定性，前后环内固定要优于单纯后环内固定。     

Failure of reduction with an external fixator in the management of injuries of the pelvic ring. Long-term evaluation of 110 patients

We reviewed 110 patients with an unstable fracture of the pelvic ring who had been treated with a trapezoidal external fixator after a mean follow-up of 4.1 years. There were eight open-book (type B1, B3-1) injuries, 62 lateral compression (type B2, B3-2) and 40 rotationally and vertically unstable (type C1-C3) injuries. The rate of complications was high with loss of reduction in 57%, malunion in 58%, nonunion in 5%, infection at the pin site in 24%, loosening of the pins in 2%, injury to the lateral femoral cutaneous nerve in 2%, and pressure sores in 3%. The external fixator failed to give and maintain a proper reduction in six of the eight open-book injuries, in 20 of the 62 lateral compression injuries, and in 38 of the 40 type-C injuries. Poor functional results were usually associated with failure of reduction and an unsatisfactory radiological appearance. In type-C injuries more than 10 mm of residual vertical displacement of the injury to the posterior pelvic ring was significantly related to poor outcome. In 14 patients in this unsatisfactory group poor functional results were also affected by associated nerve injuries. In lateral compression injuries the degree of displacement of fractures of the pubic rami caused by internal rotation of the hemipelvis was an important prognostic factor. External fixation may be useful in the acute phase of resuscitation but it is of limited value in the definitive treatment of an unstable type-C injury and in type-B open-book injuries. It is usually unnecessary in minimally displaced lateral compression injuries.     

垂直不稳定骨盆骨折的手术治疗

目的：探讨切开复位内固定治疗垂直不骨盆骨折的疗效。方法：作者２年来采用切开复位内固定治疗垂直不稳定骨盆骨折１５例。固定方法有：前环骨折采用钢板固定;后环骨折分离采用骶骨棒,四孔方形钢板,松质骨螺钉固定。结果：随访时已有１２例下地行走,无腰腿痛,患肢缩短等并发症。结论：垂直不稳定骨盆骨折手术治疗的疗效满意。     

骶髂螺钉固定治疗垂直不稳定骨盆后环骨折的疗效分析

目的评价骶髂螺钉治疗不稳定型骨盆骨折的临床疗效。方法采用骶髂螺钉治疗42例不稳定型骨盆骨折。应用Tornetta复位情况评价表评估复位情况,应用Majeed骨盆骨折评分系统评价疗效。结果 42例均获随访,随访时间为4~34个月,平均15个月。闭合复位骶骨钉内固定骨盆骨折后环不稳术后分疗效满意。结论掌握骶骨置钉技巧,应用骶骨钉固定骨盆骨折后环不稳,手术操作简单、疗效好、适于基层医院广泛开展。     

Vertically unstable pelvic fractures fixed with percutaneous iliosacral screws: does posterior injury pattern predict fixation failure?

OBJECTIVE: To measure the failure rate of percutaneous iliosacral screw fixation of vertically unstable pelvic fractures and particularly to test the hypothesis that fixations in which the posterior injury is a vertical fracture of the sacrum are more likely to fail than fixations with dislocations or fracture-dislocations of the sacroiliac joint. DESIGN: Retrospective review. SETTING: Level 1 trauma center. METHODS: All patients with pelvic fractures admitted between January 1, 1993, and December 31, 1998, were identified from the trauma registry. Hospital records were used to identify patients treated with iliosacral screws. Radiologic studies were examined to identify patients who had unequivocally vertically unstable pelvic fractures. Immediate postoperative and follow-up anteroposterior, inlet, and outlet radiographs from a minimum of 12 months postinjury were examined. Position, length, and numbers of iliosacral screws and any evidence of screw failure (eg, bending or breakage) were recorded. Residual postoperative displacement and late displacement of the posterior pelvis were measured. The main outcome measure was failure, defined as at least 1cm of combined vertical displacement of the posterior pelvis compared with immediate postoperative position. The main analysis was for association between fracture pattern and failure. Patient demographic data, iliosacral screw position, and anterior pelvic fixation method also were studied. RESULTS: The study group comprised 62 patients with unequivocally vertically unstable pelvic fractures in whom the posterior injury was treated with closed reduction and percutaneous iliosacral screw fixation. Of patients, 32 had dislocations or fracture-dislocations of the sacroiliac joint, and 30 had vertical fractures of the sacrum. Fixation failed in four patients, all with vertical sacral fractures and all within the first 3 weeks after surgery. These four patients required revision fixation. In two further cases with vertical sacral fractures, there was evidence that the fracture had only barely been held by the fixation, but these fractures healed, and follow-up radiographs did not meet the displacement criteria for failure. A vertical sacral fracture pattern was associated significantly with failure (Fisher exact test, P = 0.04); the excess risk of failure compared with sacroiliac joint injury was 13% (95% confidence interval 1% to 25%). There was no significant association between failure and anterior fixation method, iliosacral screw arrangement or length, or any demographic or injury variable. CONCLUSIONS: Percutaneous iliosacral screw fixation is a useful technique in the management of vertically unstable pelvic fractures, but a vertical sacral fracture should make the surgeon more wary of fixation failure and loss of reduction.     

S1椎弓根螺钉结合髂骨板间螺钉治疗骶髂关节骨折脱位

目的 探索S1椎弓根螺钉结合髂骨板问螺钉治疗骶髂关节骨折脱位的临床疗效，评价两者结合对骶髂关节骨折脱位的治疗价值。方法 对11例骶髂关节骨折脱位患者用脊柱内固定系统(TSRH)之S1椎弓根螺钉结合髂骨板间螺钉进行固定，该组患者涉及骶髂关节的垂直移位及旋转的骨盆环变形，归于Tile分型的B类或C类骨盆损伤。11例患者均伴有前环损伤，其中9例予以加压钢板(smith nephew)内固定，余2例患者单纯采用后路手术内固定。结果 7例患者垂直移位完全复位，9例旋转畸形纠正，未发现感染及神经损伤等并发症。结论 S1椎弓根螺钉结合髂骨板问螺钉固定技术治疗骶髂关节骨折脱位，可获得即刻稳定性并良好地维持了复位的效果．这一混合技术对于涉及垂直及旋转损伤的骨盆环损伤有稳定的作用。     

Computed tomography-guided screw fixation of a sacroiliac joint dislocation fracture: a case report

A 19-year-old woman sustained a vertical shear type pelvic fracture. Sacroiliac fixation using computed tomography (CT)-guided cannulated screws was performed for a left sacroiliac dislocation fracture, and a satisfactory result was obtained over time. Patients who have posterior instability of the lateral compression or vertical shear type do not obtain adequate stability by fixation of the anterior part alone; and they often have persistent residual pain, necessitating internal fixation of the posterior part later. Advantages of CT-guided sacroiliac screw fixation include precise evaluation of the degree of reduction and absence of nerve and vascular damage during the time the screw is inserted into the sacral body. This procedure is a useful, safe method owing to its minimal invasiveness in patients with unstable pelvic fractures that are reducible by manual manipulation or traction.     

Midline sagittal sacral fractures in anterior-posterior compression pelvic ring injuries

OBJECTIVE: To evaluate the outcome of an uncommon variant of the anterior-posterior compression pelvic injury, in which the posterior ring injury is a midline sagittal sacral fracture extending into the spinal canal. DESIGN: Prospective, consecutive series.SETTING Two regional trauma centers. PATIENTS: A consecutive series of 10 patients with rotationally displaced, vertically stable anterior-posterior compression pelvic ring fractures (OTA type 61-B1) in which the posterior ring injury is a midline sagittally oriented sacral fracture involving the spinal canal (Denis zone III). This injury pattern comprised 0.6% of pelvic fractures and 1.4% of sacral fractures treated at these two institutions during a 10-year period. INTERVENTION: Patients were treated according to the same principles used in more commonly seen types of anterior-posterior compression pelvic ring injuries. Nine patients were treated with reduction and anterior pelvic stabilization at an average of 5 days after injury, 8 of whom were treated with open reduction and internal fixation and 1 with external fixation. No posterior pelvic fixation was used. One patient with nondisplaced bilateral pubic ramus fractures was treated nonoperatively. Immediate weight bearing was allowed as tolerated. MAIN OUTCOME MEASUREMENTS: Prospectively collected clinical follow-up data emphasized a detailed neurologic examination, whereas radiographic evaluation involved anteroposterior, inlet, and outlet plain radiographic views of the pelvis. RESULTS: An anatomical or near-anatomical reduction of the pelvis was achieved and maintained in all patients. Fractures healed at an average of 10 weeks. At an average follow-up of 31 months (range 20-46 months), there were no objective neurologic deficits that could be attributed to sacral root injury and no significant residual pain or gait disturbance related to the pelvic fracture. Loss of bowel or bladder function, loss of perianal sensation or sphincter tone, and lumbosacral radicular pain or sensorimotor deficit were specifically absent in all patients. Three patients, however, complained of sexual dysfunction at final follow-up. None of these patients had clinical evidence of sacral root/plexus injury secondary to the fracture. One additional patient, who sustained a urethral tear, required a chronic suprapubic catheter because of stricture. Six patients, one of whom had needed repair of a retroperitoneal bladder tear, had no urogenital sequelae. DISCUSSION AND CONCLUSION: Patients who sustain sagittally oriented midline fractures of the sacrum that extend into the spinal canal (Denis zone III) as part of displaced, vertically stable anterior-posterior compression pelvic injuries, have a low incidence of neurologic deficit attributable to sacral root or plexus injury. This is in contrast to the high rate of neurologic deficit (>50%) otherwise reported in zone III sacral fractures, particularly in those associated with a displaced transverse component. In the midline sagittal fracture variant, simultaneous lateral displacement of both bony and neural elements through the midline may protect the sacral roots and plexi from significant traction or shear injury by maintaining the spatial orientation between the sacral foramina and sciatic notch. Long-term sequelae were related to urogenital complaints rather than to musculoskeletal problems, as 4 of the 10 patients in this series had either sexual or urologic dysfunction.     

Open reduction and internal fixation of an unstable pelvic ring injury during pregnancy

We report a case of an unstable vertical shear injury of the pelvis in a pregnant patient with a viable foetus. The combination of skeletal traction and pelvic external fixation failed to achieve satisfactory reduction. Open reduction and internal fixation of the pubic symphysis and the left sacro-iliac joint were performed without affecting the pregnancy. At the one-year follow-up, the patient was completely asymptomatic. We feel that surgical treatment of pelvic fractures can be offered to pregnant patients after thoroughly considering the potential benefits and dangers of surgery to the patient and the foetus.     

不稳定性骨盆骨折的手术内固定治疗

目的探讨不稳定性骨盆骨折内固定手术治疗的临床疗效.方法41例不稳定性骨盆骨折采用开收复位加内固定手术治疗.前环骨折采用耻骨联合上方弧形切口或经腹股沟入路．应用钛合金重建钢板内固定；后环骨折分别采用骶骨棒、骶髂拉力螺钉固定.结果41例均获随访．时间3～36个月，骨折愈合时间为2．0～3．5（2．5±0．4）个月。疗效评估：优14例，良18例，中8例．差1例.结论不稳定性骨盆骨折采用手术内固定叮以重建有效骨盆稳定性，疗效满意。