Basic principles of
treatment of breaks of lower
extremity and pelvis.
Reader: Kostiv S. Ya.
Tibia Fractures, Open
When an individual presents with an open
tibial fracture, the physician strives to save
the life of the patient and the limb, to unite
the fracture, and to prevent infection.
Maintaining a functional limb is the goal;
when that is not possible, the physician
must consider amputation.
Frequency
Behrens et al reported an incidence of 2
open tibia fractures per 1000 injuries per
year in a defined population group in an
industrialized western society; this is 0.2%
of all injuries (Behrens, 1982; Behrens,
1986). The incidence and severity may be
even higher in the developing worl
Etiology
Motor vehicle accidents, skiing accidents, and
high-energy falls are the common causes. The
mechanism of injury determines the fracture
configuration (eg, skiing injuries typically cause
spiral fractures). Most fractures are comminuted.
Pedestrians who are hit in the upper and middle
one third of the tibia sustain bumper injuries.
Distal tibial and plafond fractures are commonly
a result of a fall from a significant height.
Presentation
All persons who have undergone high-energy trauma
should be examined in accordance with the principles
defined by the Road Trauma Committee of the Royal
Australasian College of Surgeons/Emergency
Management of Severe Trauma (Geller, 1997; Shuler,
1996). The primary survey includes the ABCs (ie, airway,
breathing, circulation). A Glasgow Coma Scale score
indicates the severity of any head injury component. The
secondary survey should include the chest, abdomen,
and pelvis for associated injuries, as well as the upper
limbs and the contralateral lower limb. The ipsilateral
limb also may have other fractures, such as a femur
fracture, leading to a floating knee, or joint injuries such
as knee dislocations.
Classification
Table Type
Wound Description Other Criteria
I
<1 cm (so-called puncture wounds)
II
1-10 cm
IIIA >10 cm, coverage available Segmental fractures, farm injuries,
or any injury occurring in a highly contaminated environment
High-velocity gunshot injuries
IIIB 10 cm, requiring soft tissue coverage procedure Periosteal stripping
IIIC
With vascular injury requiring repair
Type Wound Description Other Criteria
I
<1 cm (so-called puncture wounds)
II
1-10 cm
IIIA >10 cm, coverage available Segmental fractures, farm injuries,
or any injury occurring in a highly contaminated environment
High-velocity gunshot injuries
IIIB 10 cm, requiring soft tissue coverage procedure Periosteal stripping
IIIC
With vascular injury requiring repair
Gustilo-Anderson Classification of
Open Fractures
Tscherne Classification of Soft
Tissue Injuries
Indications
The various limb salvage scoring systems, such as the MESS (Mangled
Extremity Severity Score), are good indicators for salvage but poor
indicators for amputation; thus, a limb with a good MESS usually should be
salvaged, but a limb with a poor MESS does not necessarily require
amputation.
Regarding nailing versus external fixation, Bhandari et al reported from a
meta-analysis that compared with external fixation, the use of unreamed
nails decreased the risk of reoperation, superficial infection, and malunion in
persons with open tibial fractures (Bhandari, 2001; Bhandari, 2000). They
also found a reduced risk of reoperation with using reamed nails compared
with unreamed nails. This appears to support some authors who have
suggested initial nailing with a small-diameter nail and subsequent
exchange nailing with a larger-diameter reamed nail. Plate fixation was
found to be uniformly the worst of all methods of internal fixation. Although it
may be tempting to use plate fixation for a fracture that is exposed (ie,
because of the open nature of injury), the risk of nonunion, malunion, and
deep infection is too high to justify the action (Bhandari, 2001).
Contraindications
Absolute contraindications to limb salvage
are a completely mangled limb, the
presence of warm ischemia for longer than
6 hours, and poor facilities for salvage.
Absolute contraindications to nailing an
open fracture are untreated compartment
syndrome and types IIIB and IIIC open
fractures.
Medical Therapy
ntravenous antibiotics are administered promptly. First-generation
cephalosporins (gram-positive coverage) such as cephalothin (1-2 g
q6-8h) suffice for Gustilo-Anderson type I fractures. An
aminoglycoside (gram-negative coverage) such as gentamycin (120
mg q12h; 240 mg/d) is added for types II and III injuries. Additionally,
metronidazole (500 mg q12h) or penicillin (1.2 g q6h) can be added
for coverage against anaerobes. Tetanus prophylaxis should be
instituted. Antibiotics generally are continued for 72 hours following
wound closure.
After initial assessment, the wound is irrigated in the emergency
department. A sterile dressing is applied, and the limb is splinted.
Debridement should be performed in the operating room as soon as
feasible. Debridement within 6 hours is necessary to keep the rate of
infection low (Kindsfater, 1995). A key factor in infection prevention
is early, rigid stabilization of the fracture.
Surgical Therapy
Fracture repair
Amputation
Complications
Open tibial fractures have higher rates of
nonunion, infection, and CPS.
Osteomyelitis may occur and can be acute,
subacute, or chronic. It may surface many
months or years after injury.
Pin site infections are common with external
fixator treatment. Chronic osteomyelitis in the pin
sites is relatively common.
Femoral Neck Stress and
Insufficiency Fractures
Introduction
Femoral neck stress fractures are a common
cause of hip pain in select populations. Chronic,
repetitive activity that is common to runners and
military recruits predisposes these populations
to femoral neck stress fractures. These injuries
must be differentiated from insufficiency
fractures, which, although similar in appearance
and presentation, result from an entirely different
pathophysiology and occur in a different
population.
Problem
The femoral neck area is subjected to large
compressive and sheer forces associated with
ambulation. Even in the most sedentary
individual, the daily cyclic loading of the hip and
femoral neck produces high stresses on the
bony trabeculae in this anatomic region. In longdistance runners and other high-performance
athletes, the forces across the femoral neck are
multiplied exponentially because the athletes'
training regimens place tremendous physical
burdens on this relatively small bridge of bone,
which connects the femoral head to the
diaphysis.
Frequency
Femoral neck stress fractures occur most commonly in 2 subsets of the
population. Elite distance runners, military recruits, and dancers constitute
the first group. The true prevalence of fractures in this group is difficult to
pinpoint because such patients with hip pain and femoral neck stress
fractures who never present to a physician and whose fractures go on to
heal spontaneously are never identified. Data from several military hip
fracture studies by Stoneham and Morgan, in Britain, and Volpin and
colleagues, in Israel, place the prevalence at 0.2-4.7% in patients without a
history of a single traumatic episode.3, 4 The prevalence of stress fractures
in the general population may be surmised to be far less than that
demonstrated in these 2 groups.
The second group comprises hypoestrogenic (postmenopausal) women and
individuals with pathologic entities resulting in osteopenia (eg, osteoporosis,
Paget disease, hyperparathyroidism). Fractures in this group are termed
insufficiency fractures, because bone quality is insufficient to support the
diurnal physiologic demands placed on it.
Etiology
Femoral neck stress fractures in young, otherwise healthy individuals are
related to the inability of bony trabeculae weakened by osteoporosis to
withstand physical stresses. Unusually high physical demands on normal
bone over the long term can lead to mechanical failure of the bone
trabeculae. The phenomenon is seen with exercise beyond the point of
muscle fatigue, alterations of ground reactive forces that yield abnormal
stress patterns in bone, and increased muscular contractions. Contrast this
with insufficiency fractures of the femoral neck, which are the result of
normal stresses of everyday activity placed on structurally compromised
bone. Thus, insufficiency fractures occur in individuals who have
concomitant metabolic derangements, such as hyperparathyroidism and
renal failure, or menopause.
At least 1 example of a crossover group exists: amenorrheic female
athletes. Due to their lack of body fat, female distance runners often
temporarily halt their menstrual cycle. As a result, they become
hypoestrogenic and, therefore, physiologically similar to postmenopausal
females.
Pathophysiology
A closer look at the genesis of a stress fracture in the femoral neck
reveals that the damage manifested on the physical level derives not
from a traumatic event per se but rather from a metabolic
derangement. Bone initially responds to increased mechanical
loading by increasing resorption. Resorption is normally
counterbalanced by an equal but opposite, osteoblast-mediated
metabolic repair. Under situations of extraordinarily high levels of
training, such as those faced by military personnel and elite athletes,
bone resorption begins to exceed the bone's capacity to remodel.
Additionally, pharmacologic (glucocorticoids), nutritional (vitamin D
and calcium deficiency), and other (postmenopausal,
hyperparathyroid) states can adversely affect osteoblasts' ability to
keep pace with osteoclastic resorption. If this metabolic imbalance
persists, microfractures develop that eventually weaken bone to the
point of a complete fracture.
Presentation and examination
Although femoral neck stress fractures are relatively uncommon in the
general population, they must be part of any thorough physician's
differential diagnosis for an athlete presenting with anterior hip or groin pain.
A history of insidious hip or groin pain that is directly related to an increase
in the level or duration of athletic activity and that is relieved by rest is
typical. Early diagnosis is often difficult because of the lack of an identifiable
traumatic event, which tends to dissuade primary care physicians from
obtaining radiographs. Even the astute physician ordering hip films upon
first presentation may overlook this diagnosis because fracture callus is not
evident early in the process. A bone scan may be helpful in cases in which
suspicion is high but radiographic findings are equivocal. The higher degree
of sensitivity of bone scanning is useful in detecting stress fractures and
other forms of periosteal injury without complete fracture.
In patients presenting with hip pain and negative findings during the initial
workup, obtaining plain radiographs of the ipsilateral knee also should be
considered. Referred pain along the course of the anterior branch of the
obturator nerve may manifest as ipsilateral hip pain and should be in the
clinician's differential diagnosis, especially in younger patients.
Indications
Surgical treatment is warranted for all stress fractures that have
progressed to a transverse fracture of the femoral neck. The
question then becomes which treatment procedure is more
beneficial to the patient. The orthopedist may choose either internal
fixation or arthroplasty. The decision-making process should include
consideration of the patient's bone quality, life expectancy,
physiologic status, and overall activity level. However, the main
factor in deciding which type of repair to undertake should be the
likelihood of revision surgery being needed in the future for a failed
arthroplasty. For most younger individuals in otherwise good health,
this means internal fixation of the fracture is warranted.
Indications for hemiarthroplasty include such factors as pathologic
bone, rheumatoid arthritis, renal failure or other chronic illness, and
limited lifespan.
Contraindications
In general, nondisplaced, compression-type femoral neck fractures
are relative contraindications to surgery. In contrast, tension-type
stress fractures demand surgical treatment because they have a
high propensity for fracture displacement. Contraindications to
surgical fixation of a tension-type femoral neck fracture are few
because this is one of the few true orthopedic surgical emergencies.
If a displaced femoral neck fracture occurs, the very real possibility
of disruption of blood supply to the femoral head makes surgery
necessary. Absolute contraindications include a medically unstable
patient who would be unable to tolerate the stress of surgery and
anesthesia. If initial operative fixation is not obtained and
osteonecrosis ensues, the patient, when stabilized, will require a
hemiarthroplasty as definitive treatment.
Laboratory Studies
No particular laboratory studies aid in the diagnosis of
this disorder; however, a prudent part of the preoperative
workup is the ordering of standard laboratory tests (eg,
blood chemistries, hemoglobin and hematocrit values,
and coagulation profile). When an insufficiency fracture
is suspected, the medical workup should include a
search for metabolic abnormalities, including abnormal
calcium, phosphate, and alkaline phosphatase values.
If septic arthritis of the hip is suspected, a C-reactive
protein level, erythrocyte sedimentation rate, and WBC
count with differential should help rule out an infectious
process.
Imaging Studies
Plain radiography remains the initial imaging examination in the
evaluation of suspected hip disease. A standard hip radiographic
series includes an AP view of the pelvis and coned-down AP and
frog-lateral views of the affected hip.
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
The AP view of the pelvis allows evaluation of the contralateral hip for
concomitant disease and can be used to exclude osseous or articular
abnormalities of the pelvis (eg, sacroiliitis, sacral stress fractures, pubic
ring fractures) that could present clinically as hip pain. The AP views of
the pelvis and hip are obtained with the feet internally rotated.
The frog-lateral view of a hip is obtained with the radiographic beam
oriented in the AP direction, with the hip abducted. A groin lateral view of
the hip, instead of the frog-lateral view, can be used in cases of an
acute femoral neck fracture or displaced fracture, because the affected
hip remains in a neutral position. In this examination, the opposite leg is
abducted and elevated and the radiographic beam is oriented parallel to
the table, with 20° cephalad angulation.
Imaging Studies
In the case of a compression-type fracture, the inferior aspect of the femoral
neck demonstrates cortical thickening with a hazy, radiolucent center. This
radiographic picture may be easily confused with osteoid osteoma if an
adequate history is not obtained from the patient. Transverse-type fractures
appear much differently on radiography, the first sign being a faint line of
sclerosis across the femoral neck. If left untreated, these transverse
fractures may easily progress to complete neck fractures, with significant
displacement and varus angulation.
Because of its sensitivity in detecting periosteal injury, bone scanning has
been very helpful in the absence of conventional radiographic findings. In
the presence of stress fractures, bone scanning demonstrates focal
increased uptake of the radiotracer, at the fracture site. This represents an
area of increased bone turnover. One drawback to this modality, however, is
that findings on scintography are often negative during the first 24 hours
after stress fracture. The positive predictive value of radionuclide imaging in
diagnosing femoral neck stress pathology approaches 68%.
Imaging Studies
Having similar sensitivity and the added advantage of greater
specificity for stress fractures, MRI has become the new modality of
choice for detecting stress pathology. In several studies, both the
sensitivity and specificity of MRI in detecting femoral neck stress
fractures was 100%. However, with this increased specificity comes
increased price for the testing modality. In addition to being less
invasive than bone scanning (no radiotracer needs to be injected),
MRI provides much more information about the surrounding soft
tissues. MRI has been shown to be effective in differentiating stress
fracture from malignancy or infection.
A diagnostic MRI of a femoral neck stress fracture depicts
decreased signal intensity on T1-weighted images and increased
signal intensity on T2, as well as short TI inversion recovery (STIR)
images with or without a low signal fracture line.
Outcome and Prognosis
he prognosis for femoral neck stress fractures depends largely on
the classification of the fracture. Compression-type injuries
historically fare very well, with the patient recovering full preinjury
function after diligent adherence to a physician-prescribed plan of
limited weightbearing and walking with an aid. Transverse-type
fractures, when identified early and with the only radiographic
abnormality being sclerotic changes, tend to recover well after
internal fixation. Potential lasting effects of surgical management
include hip pain and nonunion or malunion of the fracture. The worst
prognosis exists for transverse fractures that are inherently unstable
because of mechanical reasons and that can progress to complete
displaced fractures. The rate of nonunion and AVN in these cases is
as high as 35%, according to some authors.
Future and Controversies
Debate currently exists over the surgical treatment of transversetype femoral neck stress fractures in older patients. Given that most
individuals who sustain true stress fractures (as distinguished from
insufficiency fractures) are young and healthy, only a small number
of individuals are affected by this controversy.
The 2 current methods of fixation include internal fixation and
prosthetic replacement. Multiple studies comparing the 2 modalities
of fracture fixation for these types of injuries have demonstrated
widely varying results. Infection rates, morbidity, mortality, and
patient satisfaction have been examined without a definitive answer
gleaned. Additionally, the prosthetic opponents point out that the
cost and potential complications of the components are not
justifiable for individuals whose remaining life expectancy might be
half that of the implant.
Anteroposterior and lateral images of a 54-year-old woman with a 2-month
history of right groin pain with ambulation. Note sclerosis of the right femoral
neck running perpendicular to trabeculae.
Anteroposterior and lateral images of a 54-year-old woman with a 2-month
history of right groin pain with ambulation. Note sclerosis of the right femoral
neck running perpendicular to trabeculae.
Anteroposterior and lateral images of a 54-year-old woman with a 2-month
history of right groin pain with ambulation. Note sclerosis of the right femoral
neck running perpendicular to trabeculae.
Anteroposterior and lateral images of a 54-year-old woman with a 2-month
history of right groin pain with ambulation. Note sclerosis of the right femoral
neck running perpendicular to trabeculae.
Pelvic Fractures
Problem
Unstable 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).
Frequency
The 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).
Etiology
Pelvic 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.
Indications
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).
Tile classification scheme for pelvic
fractures is as follows (Tile, 1995):
Type A - Rotationally and vertically stable
A1 - Avulsion fractures
A2 - Stable iliac wing fractures or minimally displaced pelvic ring
fractures
A3 - Transverse sacral or coccyx fractures
Type B - Rotationally unstable and vertically stable
B1 - Open-book injuries
B2 - LC injuries
B3 - Bilateral type B injuries
Type C - Rotationally unstable and vertically unstable
C1 - Unilateral injury
C2 - Bilateral injuries in which one side is a type B injury and the
contralateral side is a type C injury
C3 - Bilateral injury in which both sides are type C injuries
Laboratory Studies
A complete blood cell count, renal panel,
coagulation profile, and toxicology screens
usually are obtained in the emergency
department upon patient presentation.
Serial hematocrits are helpful in the acute
setting to monitor resuscitation efforts.
Imaging Studies
Anteroposterior pelvic radiograph
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
Obtained as component of the initial trauma evaluation
Highlights most major pelvic disruptions (Young, 1987)
Inlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980)

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X-ray tube angled 45° caudad and centered on the umbilicus
Highlights AP and mediolateral translations, and internal and external
rotatory deformities
Outlet pelvic radiograph (Pennal, Tile, Waddell, Garside, 1980)


X-ray tube angled 45° cephalad and centered on the symphysis pubis
Highlights superior and inferior translations abduction and/or adduction,
and flexion and/or extension rotational deformities
Lateral sacral radiograph (Nork, 2001; Roy-Camille, 1985)


Indicated in injuries sustained from falls and when bilateral sacral
fractures are noted on plain radiographs or CT scans
Demonstrates transverse fracture of sacral body and /or kyphosis of
sacrum
Imaging Studies
Pelvic CT scans

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Useful to confirm plain film findings and more to document sacral morphology
when planning percutaneous iliosacral screw placement (Routt, 2000)
Often can be included with abdominal CT scans
Five-millimeter axial images from iliac crests to acetabular dome, then 3-mm
axial images including all acetabular articular segments, then 5-mm slices
through remainder of caudal pelvis (Routt, Orthop Clin North Am, 1997)
Three-dimensional reformatted pelvic CT scans also may be beneficial to
highlight pelvic ring injuries and associated deformity patterns.
Pelvic angiograms
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Indicated in patients with ongoing hemorrhage after adequate intravenous fluid
resuscitation and provisional pelvic ring stabilization
Useful in patients who have pelvic ring or acetabular injuries involving the greater
sciatic notch to detect obvious or occult injury to the superior gluteal artery
Embolization of lacerated arterial vessels may be performed at the same setting,
as can manipulative reductions using the angiography fluoroscopic imaging
system
Imaging Studies
Retrograde urethrogram
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Indicated in patients suspected of having
urethral tears
Recommended to be performed under the
direction of a urologist
Cystogram
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
Indicated in patients suspected of having a
urinary bladder injury
Recommended to be performed under the
direction of a urologist
Medical Therapy
Initial 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):
A = Airway with cervical spine control
B = Breathing
C = Circulation
D = Disability or neurologic status
E = Exposure (undress) with temperature control
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 Therapy
Symphysis pubis disruptions

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.
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
liac 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
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).
Sacroiliac joint disruptions
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.
Sacral fractures
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.
Complications
Muscle ruptures and hernias
Neurologic injury
Postoperative wound infection
Proximal DVTs
Genitourinary
Outcome and Prognosis
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).
Anterior-posterior (AP) compression pelvic fracture.
Vertical shear (VS) fracture pattern.
Denis zone II sacral fracture
Crescent fracture on CT sca
Anterior-posterior compression pelvic fracture
with an associated Denis zone II sacral fracture.
(The symphysis was plated with a 3.5-mm
reconstruction plate, and the sacrum was fixed
with iliosacral screws.)