International
International Orthopaedics (SICOT) 3,183-188 (1979)
Orthopaedics © Springer-Verlag 1979
External Fixation of Unstable Pelvic Fractures E. B. R i s k a , H . y o n B o n s d o r f f , S. H a k k i n e n , H. J a r o m a , O. K i v i l u o t o , a n d T. P a a v i l a i n e n Department of Orthopaedics and Traumatology, University of Helsinki, Finland
Summary. The Hoffmann external fixator was used to stabilize unstable pelvic fractures in 56 patients with multiple injuries. It was applied under general anaesthesia and the dislocated pelvis reduced and secured with a single tie bar. In 16 cases residual dislocation of less than 1.5 cm was noted after the reduction and the reduced position was maintained in 48 out of 51 cases, a minor redislocation occurred in the remaining 3 patients. Few complications could be attributed to the method, infection was noted in one patient, the iliac crest was fractured in one case and an exostosis of the iliac crest occurred in one youth. Forty-three patients were symptom free with regard to the pelvis at the time of review whereas 5 patients had residual pain and 3 diffuse symptoms. The technique of application is simple but requires two surgeons at the time of reduction and fixation of the pelvis. R 6 s u m ~ . Les auteurs ont utilisg le fixateur externe
d'Hoffmann pour maintenir une fracture instable du bassin chez 56 blessds prdsentant des traumatismes multiples. Le fixateur a dtd mis en place sous anesthdsie gdndrale et le bassin fracturd rdduit et maintenu par une barre simple. Dans 16 cas, il persistait apr@s rdduction une disjonction inf~rieure g~ 1,5 cm. La position de r(duction sSest maintenue dans 48 des 51 cas, tandis qu' un reddplacement modgrg s' est produit dans les 3 autres cas. II n' y a eu qu' un petit nombre de complications dues g~ la m~thode: une infection, une fracture de la cr@te iliaque et une exostose de la cr@te iliaque chez un sujet jeune. Quarante-trois blessds ne prdsentaient aucune s~quelle en ce qui concerne le bassin lors de l'examen de contr61e, tandis que cinq signalaient des douleurs r~siduelles et trois des troubles divers. Address offprint requests to: E. B. Riska, Department of Orthopaedics and Traumatology, University Central Hospital of Helsinki, Topeliuksenkatu 5, 00260 Helsinki 26, Finland
Cette technique est de rdal&ation facile mais elle ndcessite la prdsence de deux chirurgiens pour effectuer la rdduction et la fixation du bassin.
Key w o r d s : External fixation, Pelvic fractures T h e t r e a t m e n t of u n s t a b l e p e l v i c f r a c t u r e s o f t e n poses a difficult p r o b l e m b e c a u s e t h e y f r e q u e n t l y o c c u r in a s s o c i a t i o n with m u l t i p l e a n d s e v e r e l i f e - t h r e a t e n i n g injuries t h a t m a y r e q u i r e i m m e d i a t e surgical i n t e r vention. N e v e r t h e l e s s , e a r l y o p e r a t i v e f i x a t i o n of a pelvic a n d long b o n e f r a c t u r e s o f t e n facilitates t h e m a n a g e m e n t of t h e o t h e r injuries, a n d m a y p e r m i t early m o b i l i s a t i o n of t h e p a t i e n t [6]. B e t w e e n 1972 a n d 1976, in o u r clinic, 56 p a t i e n t s with u n s t a b l e pelvic f r a c t u r e s w e r e t r e a t e d w i t h t h e H o f f m a n n e x t e r n a l fixator. O f these, 52 p a t i e n t s h a d m u l t i p l e injuries a n d w e r e in n e e d of e m e r g e n c y surgery. T h e m e t h o d of r e d u c t i o n a n d fixation of t h e pelvis a n d t h e results of t r e a t m e n t will b e p r e s e n t e d in this r e p o r t .
Material Of the 56 patients, 35 were men and 21 women; 8 were aged between 10 and 19 years, 33 between 20 and 49, and 15 were aged over 50 years at the time of admission. Seventeen had fallen from a height and 38 were victims of road traffic accidents (Table 1).
Table 1. Patients with unstable pelvic fractures treated with Hoffmann's external fixation Age Years
Sex Mechanism of injury Male Female Fall from Traffic height accident
10-19 20-49 50-76
6 19 10
2 14 5
1 13 3
7 19 12
1
Total
35
21
17
38
1
Occupational accident
0341-2695/70/0003/0183/$
0.120
184
E.B. Riska et al.: External Fixation of Unstable Pelvic Fractures
Fig. 1 A - E . Types of pelvic fractures. A Hemipelvic fracture (13 cases). B Hemipelvic fracture with complete fracture of the anterior segment (27 cases). C Hemipelvic fracture with bilateral fracture of the posterior segment (5 cases). D Bilateral hemipelvic fracture (8 cases). E Severely comminuted type of pelvic fracture (3 cases)
Associated injuries were present in most of the patients and these were long bone fractures 53, cerebral injuries 19, urogenital tract injuries 16, intra-abdominal injuries 8, fractures of the spine 15, injuries of the chest 14, and facial bone fractures 8, (Chart 1).
Diagnosis The stability of the pelvic ring was easily tested by grasping the iliac crest on each side close to the anterior iliac spine. An unstable pelvis might be
opened or closed by applying stress in either a horizontal or vertical direction. Subsequent X-ray examination gave more information about the position and type of fracture. Urethro-cystography, which gave detailed information of possible soft tissue injuries, was performed in all cases. Clinical examination for pelvic stability is most important because stable pelvic fractures do not require fixation and may be treated conservatively
185
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures
Chart 1. Associated injuries of 56 patients with pelvic fractures treated with Hoffmann's external fixation Number of patients 39
19 :'~:i : ::
......... Lower extremity
;ociated lries Brain
Urogenital apparatus
Spine
Thorax
Upper extremity
Abdomen
Facial bones
Table 2. Type of pelvic fracture of 56 patients treated with Hoff-
Fig. 2. Hoffmann's external fixation device anchored to the pelvis of a 25-year-old man
mann's external fixation Type
A B C D E Total
No dislocation
Horizontal dislocation
Vertical dislocation
Total
4 4 1 0 1
2 10 3 6 1
7 13 1 2 1
13 27 5 8 3
I0
22
24
56
Table 3. Hoffmann's external fixation. Primary results of treatment of 56 patients with unstable pelvic fractures
without bed rest. Unstable fractures in contrast require correct treatment from the outset. In our series all 5 6 p e l v i c f r a c t u r e s w e r e u n s t a b l e ; i n 1 0 c a s e s t h e r e was no displacement, in 22 cases horizontal displacem e n t a n d i n 2 4 c a s e s v e r t i c a l d i s p l a c e m e n t ( T a b l e 2). D i a s t a s i s of t h e p u b i s h a d o c c u r r e d i n 11 p a t i e n t s . The fractures were classified into five different pattern groups shown in the Figure 1 A-E. The distribution of the 56 patients according to these g r o u p s is s h o w n i n T a b l e 2.
Method of External Fixation General anaesthesia was used in all cases. Three Hoffmann screwed pins were inserted in the anterior portion of the iliac crest on each side and directed medially, posteriorly and inferiorly [1, 3, 4]. A ball joint clamp was applied to each group of pins, sufficient force could then be applied to reduce the dislocated pelvis although in some cases additional traction on either lower limb was necessary to re-establish the normal anatomy of the pelvic ring. The position was checked with an X-ray Image Intensifier and the reduced position of the pelvis was maintained by one surgeon, while another secured the position with ball joint rods, two ball joints and one single tie bar (Fig. 2). In three cases a frame was mounted with two tie bars and in 10 cases a slider bar was used. The final position was checked with antero-posterior X-ray films. In 10 patients no reduction was necessary because of existing satisfactory fracture alignment. In 30 patients a good anatomical position was achieved. In 16 cases dislocation of less than 1.5 cm remained following the reduction; in four of these there was a
Result
Position maintained Horizontal shift less than 1.5 cm Vertical shift less than 1.5 cm Fatal outcome Total
No reduction Anatomical necessary position achieved
9
26
Residual Total dislocation after reduction
16
51
4
12 1
4
10
30
5 16
56
residual horizontal shift whilst in 12 a residual vertical shift (Table 3). The residual displacement was attributed to severe dislocation prior to reduction and further correction was not attempted. Any surgery necessary for thoracic or abdominal injuries, or for internal fixation of long bone fractures, was carried out prior to the reduction and fixation of the pelvic fracture [6].
Progress T h e a v e r a g e d u r a t i o n o f e x t e r n a l f i x a t i o n of t h e p e l v i s lasted 41 days (range 17-59 days). In one case the e q u i p m e n t w a s r e m o v e d 17 d a y s a f t e r a p p l i c a t i o n b e c a u s e o f a c r a c k i n t h e iliac c r e s t a n d i n o n e c a s e b e c a u s e of i n f e c t i o n 18 d a y s l a t e r . Thirty-three patients could be mobilised on c r u t c h e s w i t h i n s e v e n w e e k s , b u t t h e e f f e c t s o f ass o c i a t e d i n j u r i e s d e l a y e d m o b i l i s a t i o n in a f u r t h e r 18 p a t i e n t s ( T a b l e 4 ) . T h e d u r a t i o n of h o s p i t a l t r e a t m e n t w a s less t h a n 11 w e e k s f o r 3 6 p a t i e n t s a n d b e t w e e n t h r e e a n d f i v e m o n t h s f o r 1 2 p a t i e n t s ( T a b l e 4).
186
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures
Table 4. Mobilization and duration of hospital treatment of 51 patients with unstable pelvic fractures treated with Hoffmann's external fixation Time (weeks) 2- 3 4- 5 6- 7 8- 9 10-11 12-13 14-17 18 -22 Over 23 Total
Mobilization on crutches Number of patients 2 3 28 13 3 0 2 0 0 51
Duration of hospital treatment Number of patients 0 1 14 12 9 6 2 4 3 51
cases out of 51 (Fig. 3 A - C ) , which includes the cases with residual dislocation after p r i m a r y r e d u c t i o n (Fig. 4 A - C ) . I n only t h r e e cases was a r e c u r r e n c e of the dislocation n o t e d at the follow-up e x a m i n a t i o n . I n o n e case t h e r e was a w i d e n i n g of the symphysis by 1 cm a n d in two cases t h e r e were vertical shifts of 1 a n d 0.5 cm, respectively. This i n d i c a t e d that the fixation m e t h o d a p p e a r e d to be a d e q u a t e l y secure. A t the time of review 43 p a t i e n t s were free of all s y m p t o m s from the pelvic fracture, 5 p a t i e n t s had residual discomfort, m a i n l y in the r e g i o n of the s a c r u m a n d sacro-iliac joints, a n d in three cases the s y m p t o m s were diffuse (Table 6). Table 5. Follow~up time of 51 patients with unstable pelvic fractures Time
R e s u l t s of T r e a t m e n t Of the original g r o u p of p a t i e n t s five h a d died f r o m the effects of t h e i r i n j u r i e s a n d 51 p a t i e n t s were available for review after an i n t e r v a l r a n g i n g f r o m t h r e e six m o n t h s , to five years after their accident ( T a b l e 5). A t the f o l l o w - u p e x a m i n a t i o n it was n o t e d that the r e d u c e d p o s i t i o n of the pelvis was m a i n t a i n e d in 48
Number of patients
3 - 6 months 6-12 months 1- 2years 2 - 3 years 4 - 5 years Over 5 years
14 13 12 9 2 1
Total
51
Fig. 3 A-C. Unstable hemipelvic fracture with fractures of the anterior ring in a woman of 36 years before treatment (A), after reduction and fixation (B), and 2 years and 2 months after surgery (C). The result of treatment was good
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures
187
Fig. 4 A-C. Unstable pelvic fracture in a man of 62 years before treatment (A), after reduction and external fixation with residual vertical shift of 1 cm (B) and at the time of follow-up examination 2 years later (C). The reduction and the result of treatment was classified as good
Table 6. Hoffmann's external fixation Late results of treatment of 51 patients with unstable pelvic fractures Result
Number of patients
Position maintained Later dislocation Symptom free Residual pain Diffuse symptoms
48 3 43 5 3
Table 7. Causes of deaths of 5 patients with multiple injuries and unstable pelvic fractures treated with Hoffmann's external fixation Cause of death
Number of patients
Brain injury Pulmonary embolism Uraemia Profuse tracheal bleeding
2 1 1 1
Discussion Complications The iliac crest was f r a c t u r e d in o n e case a n d o n e other b e c a m e infected. O n e y o u t h d e v e l o p e d an exostosis of the iliac crest which r e q u i r e d s u b s e q u e n t surgical resection. T h e r e were five deaths in the series, o n e caused by p u l m o n a r y e m b o l i s m a n d the others due to b r a i n i n j u r y , u r a e m i a a n d t r a c h e a l b l e e d i n g ( T a b l e 7).
The H o f f m a n n e x t e r n a l fixator p r o v e d to be a good m e t h o d for the t r e a t m e n t of pelvic fractures. In 48 out of 51 cases the r e d u c e d p o s i t i o n was m a i n t a i n e d , a n d in only 3 cases did m i n o r d i s p l a c e m e n t occur subsequently. A l t e r n a t i v e p a t t e r n s of f r a m e m o u n t i n g s have b e e n suggested for fixation of pelvic fractures [2, 8], b u t these o f t e n m a k e the p o s t o p e r a t i v e n u r s i n g of associated surgical c o n d i t i o n s difficult. W e f o u n d that the use of c o m p l i c a t e d e q u i p m e n t was u n n e c e s s a r y
188 because the position could be a d e q u a t e l y maintained with one single tie bar. The technique allowed easy handling, turning and lifting of the patient so that nursing care was facilitated in c o m p a r i s o n with sling suspension [7]. In very y o u n g patients there m a y be a risk of d a m a g i n g the apophyseal plate of the iliac crest and our y o u n g e s t patient, 14 years old, later developed an exostosis on the iliac crest which required surgical removal. T h r e e other patients were 15 and 17 years old at the time of the accident and suffered no complication f r o m this cause. In five cases the patients were mobilised before the r e m o v a l of the H o f f m a n n apparatus, but most of the patients h a d multiple injuries which p r e v e n t e d mobilisation on crutches before six weeks although they were allowed to m o v e freely in bed w h e n e v e r possible. Prior to 1972, at our clinic, internal fixation of the pelvis was carried out with A O plates and screws, especially in patients with severe bleeding [5]. Alt h o u g h this m e t h o d is still used in similar cases we n o w regard the H o f f m a n n external fixator as preferable whenever, it "is indicated, and it has b e c o m e the
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures routine m e t h o d in our clinic. The technique is simple and can be carried out as an e m e r g e n c y p r o c e d u r e even at night.
References 1. Adrey, J.: Hoffmann's external anchorage coupled in frame arrangement. Paris: Gead 1971 2. Carabalona, P., Rabichong, P., Bonnel, F., Perruchon, E., Peguret, F.: Contribution of the external fixation in disjunctions of the pubis and of the sacroiliac articulation. Montpellier-Chirurgica119, 61-70 (1973) 3. Connes, D'Henry: Hoffmann's double frame external anchorage. Methods, applications and results in 16 observations. Paris: Gead 1973 4. Hoffmann, R.: Osteotaxis, guide technique et clinique. Courrier de la c6te, S. A. Nyon 1961 5. Riska, E. B., Lyytik/iinen, M.: Operatively treated pelvic fractures in 26 patients with multiple injuries. Acta Orthop. Scand. 44, 119-120 (1973) 6. Riska, E. B., von Bonsdorff, H., Hakkinen, S., Jaroma, H., Kiviluoto, O., Paavilainen, T.: Primary operative fixation of long bone fractures in patients with multiple injuries. J. Trauma 17, 111-121 (1977) 7. Schweiberer, L.: Beckenbriiche. Chirurg 41, 55-62 (1970) 8. Slfitis, P., Karaharju, O.: External fixation of the pelvic girdle with a trapezoid compression frame. Injury 7, 53-56 (1975)
International Orthopaedics (SICOT) 3,183-188 (1979)
Orthopaedics © Springer-Verlag 1979
External Fixation of Unstable Pelvic Fractures E. B. R i s k a , H . y o n B o n s d o r f f , S. H a k k i n e n , H. J a r o m a , O. K i v i l u o t o , a n d T. P a a v i l a i n e n Department of Orthopaedics and Traumatology, University of Helsinki, Finland
Summary. The Hoffmann external fixator was used to stabilize unstable pelvic fractures in 56 patients with multiple injuries. It was applied under general anaesthesia and the dislocated pelvis reduced and secured with a single tie bar. In 16 cases residual dislocation of less than 1.5 cm was noted after the reduction and the reduced position was maintained in 48 out of 51 cases, a minor redislocation occurred in the remaining 3 patients. Few complications could be attributed to the method, infection was noted in one patient, the iliac crest was fractured in one case and an exostosis of the iliac crest occurred in one youth. Forty-three patients were symptom free with regard to the pelvis at the time of review whereas 5 patients had residual pain and 3 diffuse symptoms. The technique of application is simple but requires two surgeons at the time of reduction and fixation of the pelvis. R 6 s u m ~ . Les auteurs ont utilisg le fixateur externe
d'Hoffmann pour maintenir une fracture instable du bassin chez 56 blessds prdsentant des traumatismes multiples. Le fixateur a dtd mis en place sous anesthdsie gdndrale et le bassin fracturd rdduit et maintenu par une barre simple. Dans 16 cas, il persistait apr@s rdduction une disjonction inf~rieure g~ 1,5 cm. La position de r(duction sSest maintenue dans 48 des 51 cas, tandis qu' un reddplacement modgrg s' est produit dans les 3 autres cas. II n' y a eu qu' un petit nombre de complications dues g~ la m~thode: une infection, une fracture de la cr@te iliaque et une exostose de la cr@te iliaque chez un sujet jeune. Quarante-trois blessds ne prdsentaient aucune s~quelle en ce qui concerne le bassin lors de l'examen de contr61e, tandis que cinq signalaient des douleurs r~siduelles et trois des troubles divers. Address offprint requests to: E. B. Riska, Department of Orthopaedics and Traumatology, University Central Hospital of Helsinki, Topeliuksenkatu 5, 00260 Helsinki 26, Finland
Cette technique est de rdal&ation facile mais elle ndcessite la prdsence de deux chirurgiens pour effectuer la rdduction et la fixation du bassin.
Key w o r d s : External fixation, Pelvic fractures T h e t r e a t m e n t of u n s t a b l e p e l v i c f r a c t u r e s o f t e n poses a difficult p r o b l e m b e c a u s e t h e y f r e q u e n t l y o c c u r in a s s o c i a t i o n with m u l t i p l e a n d s e v e r e l i f e - t h r e a t e n i n g injuries t h a t m a y r e q u i r e i m m e d i a t e surgical i n t e r vention. N e v e r t h e l e s s , e a r l y o p e r a t i v e f i x a t i o n of a pelvic a n d long b o n e f r a c t u r e s o f t e n facilitates t h e m a n a g e m e n t of t h e o t h e r injuries, a n d m a y p e r m i t early m o b i l i s a t i o n of t h e p a t i e n t [6]. B e t w e e n 1972 a n d 1976, in o u r clinic, 56 p a t i e n t s with u n s t a b l e pelvic f r a c t u r e s w e r e t r e a t e d w i t h t h e H o f f m a n n e x t e r n a l fixator. O f these, 52 p a t i e n t s h a d m u l t i p l e injuries a n d w e r e in n e e d of e m e r g e n c y surgery. T h e m e t h o d of r e d u c t i o n a n d fixation of t h e pelvis a n d t h e results of t r e a t m e n t will b e p r e s e n t e d in this r e p o r t .
Material Of the 56 patients, 35 were men and 21 women; 8 were aged between 10 and 19 years, 33 between 20 and 49, and 15 were aged over 50 years at the time of admission. Seventeen had fallen from a height and 38 were victims of road traffic accidents (Table 1).
Table 1. Patients with unstable pelvic fractures treated with Hoffmann's external fixation Age Years
Sex Mechanism of injury Male Female Fall from Traffic height accident
10-19 20-49 50-76
6 19 10
2 14 5
1 13 3
7 19 12
1
Total
35
21
17
38
1
Occupational accident
0341-2695/70/0003/0183/$
0.120
184
E.B. Riska et al.: External Fixation of Unstable Pelvic Fractures
Fig. 1 A - E . Types of pelvic fractures. A Hemipelvic fracture (13 cases). B Hemipelvic fracture with complete fracture of the anterior segment (27 cases). C Hemipelvic fracture with bilateral fracture of the posterior segment (5 cases). D Bilateral hemipelvic fracture (8 cases). E Severely comminuted type of pelvic fracture (3 cases)
Associated injuries were present in most of the patients and these were long bone fractures 53, cerebral injuries 19, urogenital tract injuries 16, intra-abdominal injuries 8, fractures of the spine 15, injuries of the chest 14, and facial bone fractures 8, (Chart 1).
Diagnosis The stability of the pelvic ring was easily tested by grasping the iliac crest on each side close to the anterior iliac spine. An unstable pelvis might be
opened or closed by applying stress in either a horizontal or vertical direction. Subsequent X-ray examination gave more information about the position and type of fracture. Urethro-cystography, which gave detailed information of possible soft tissue injuries, was performed in all cases. Clinical examination for pelvic stability is most important because stable pelvic fractures do not require fixation and may be treated conservatively
185
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures
Chart 1. Associated injuries of 56 patients with pelvic fractures treated with Hoffmann's external fixation Number of patients 39
19 :'~:i : ::
......... Lower extremity
;ociated lries Brain
Urogenital apparatus
Spine
Thorax
Upper extremity
Abdomen
Facial bones
Table 2. Type of pelvic fracture of 56 patients treated with Hoff-
Fig. 2. Hoffmann's external fixation device anchored to the pelvis of a 25-year-old man
mann's external fixation Type
A B C D E Total
No dislocation
Horizontal dislocation
Vertical dislocation
Total
4 4 1 0 1
2 10 3 6 1
7 13 1 2 1
13 27 5 8 3
I0
22
24
56
Table 3. Hoffmann's external fixation. Primary results of treatment of 56 patients with unstable pelvic fractures
without bed rest. Unstable fractures in contrast require correct treatment from the outset. In our series all 5 6 p e l v i c f r a c t u r e s w e r e u n s t a b l e ; i n 1 0 c a s e s t h e r e was no displacement, in 22 cases horizontal displacem e n t a n d i n 2 4 c a s e s v e r t i c a l d i s p l a c e m e n t ( T a b l e 2). D i a s t a s i s of t h e p u b i s h a d o c c u r r e d i n 11 p a t i e n t s . The fractures were classified into five different pattern groups shown in the Figure 1 A-E. The distribution of the 56 patients according to these g r o u p s is s h o w n i n T a b l e 2.
Method of External Fixation General anaesthesia was used in all cases. Three Hoffmann screwed pins were inserted in the anterior portion of the iliac crest on each side and directed medially, posteriorly and inferiorly [1, 3, 4]. A ball joint clamp was applied to each group of pins, sufficient force could then be applied to reduce the dislocated pelvis although in some cases additional traction on either lower limb was necessary to re-establish the normal anatomy of the pelvic ring. The position was checked with an X-ray Image Intensifier and the reduced position of the pelvis was maintained by one surgeon, while another secured the position with ball joint rods, two ball joints and one single tie bar (Fig. 2). In three cases a frame was mounted with two tie bars and in 10 cases a slider bar was used. The final position was checked with antero-posterior X-ray films. In 10 patients no reduction was necessary because of existing satisfactory fracture alignment. In 30 patients a good anatomical position was achieved. In 16 cases dislocation of less than 1.5 cm remained following the reduction; in four of these there was a
Result
Position maintained Horizontal shift less than 1.5 cm Vertical shift less than 1.5 cm Fatal outcome Total
No reduction Anatomical necessary position achieved
9
26
Residual Total dislocation after reduction
16
51
4
12 1
4
10
30
5 16
56
residual horizontal shift whilst in 12 a residual vertical shift (Table 3). The residual displacement was attributed to severe dislocation prior to reduction and further correction was not attempted. Any surgery necessary for thoracic or abdominal injuries, or for internal fixation of long bone fractures, was carried out prior to the reduction and fixation of the pelvic fracture [6].
Progress T h e a v e r a g e d u r a t i o n o f e x t e r n a l f i x a t i o n of t h e p e l v i s lasted 41 days (range 17-59 days). In one case the e q u i p m e n t w a s r e m o v e d 17 d a y s a f t e r a p p l i c a t i o n b e c a u s e o f a c r a c k i n t h e iliac c r e s t a n d i n o n e c a s e b e c a u s e of i n f e c t i o n 18 d a y s l a t e r . Thirty-three patients could be mobilised on c r u t c h e s w i t h i n s e v e n w e e k s , b u t t h e e f f e c t s o f ass o c i a t e d i n j u r i e s d e l a y e d m o b i l i s a t i o n in a f u r t h e r 18 p a t i e n t s ( T a b l e 4 ) . T h e d u r a t i o n of h o s p i t a l t r e a t m e n t w a s less t h a n 11 w e e k s f o r 3 6 p a t i e n t s a n d b e t w e e n t h r e e a n d f i v e m o n t h s f o r 1 2 p a t i e n t s ( T a b l e 4).
186
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures
Table 4. Mobilization and duration of hospital treatment of 51 patients with unstable pelvic fractures treated with Hoffmann's external fixation Time (weeks) 2- 3 4- 5 6- 7 8- 9 10-11 12-13 14-17 18 -22 Over 23 Total
Mobilization on crutches Number of patients 2 3 28 13 3 0 2 0 0 51
Duration of hospital treatment Number of patients 0 1 14 12 9 6 2 4 3 51
cases out of 51 (Fig. 3 A - C ) , which includes the cases with residual dislocation after p r i m a r y r e d u c t i o n (Fig. 4 A - C ) . I n only t h r e e cases was a r e c u r r e n c e of the dislocation n o t e d at the follow-up e x a m i n a t i o n . I n o n e case t h e r e was a w i d e n i n g of the symphysis by 1 cm a n d in two cases t h e r e were vertical shifts of 1 a n d 0.5 cm, respectively. This i n d i c a t e d that the fixation m e t h o d a p p e a r e d to be a d e q u a t e l y secure. A t the time of review 43 p a t i e n t s were free of all s y m p t o m s from the pelvic fracture, 5 p a t i e n t s had residual discomfort, m a i n l y in the r e g i o n of the s a c r u m a n d sacro-iliac joints, a n d in three cases the s y m p t o m s were diffuse (Table 6). Table 5. Follow~up time of 51 patients with unstable pelvic fractures Time
R e s u l t s of T r e a t m e n t Of the original g r o u p of p a t i e n t s five h a d died f r o m the effects of t h e i r i n j u r i e s a n d 51 p a t i e n t s were available for review after an i n t e r v a l r a n g i n g f r o m t h r e e six m o n t h s , to five years after their accident ( T a b l e 5). A t the f o l l o w - u p e x a m i n a t i o n it was n o t e d that the r e d u c e d p o s i t i o n of the pelvis was m a i n t a i n e d in 48
Number of patients
3 - 6 months 6-12 months 1- 2years 2 - 3 years 4 - 5 years Over 5 years
14 13 12 9 2 1
Total
51
Fig. 3 A-C. Unstable hemipelvic fracture with fractures of the anterior ring in a woman of 36 years before treatment (A), after reduction and fixation (B), and 2 years and 2 months after surgery (C). The result of treatment was good
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures
187
Fig. 4 A-C. Unstable pelvic fracture in a man of 62 years before treatment (A), after reduction and external fixation with residual vertical shift of 1 cm (B) and at the time of follow-up examination 2 years later (C). The reduction and the result of treatment was classified as good
Table 6. Hoffmann's external fixation Late results of treatment of 51 patients with unstable pelvic fractures Result
Number of patients
Position maintained Later dislocation Symptom free Residual pain Diffuse symptoms
48 3 43 5 3
Table 7. Causes of deaths of 5 patients with multiple injuries and unstable pelvic fractures treated with Hoffmann's external fixation Cause of death
Number of patients
Brain injury Pulmonary embolism Uraemia Profuse tracheal bleeding
2 1 1 1
Discussion Complications The iliac crest was f r a c t u r e d in o n e case a n d o n e other b e c a m e infected. O n e y o u t h d e v e l o p e d an exostosis of the iliac crest which r e q u i r e d s u b s e q u e n t surgical resection. T h e r e were five deaths in the series, o n e caused by p u l m o n a r y e m b o l i s m a n d the others due to b r a i n i n j u r y , u r a e m i a a n d t r a c h e a l b l e e d i n g ( T a b l e 7).
The H o f f m a n n e x t e r n a l fixator p r o v e d to be a good m e t h o d for the t r e a t m e n t of pelvic fractures. In 48 out of 51 cases the r e d u c e d p o s i t i o n was m a i n t a i n e d , a n d in only 3 cases did m i n o r d i s p l a c e m e n t occur subsequently. A l t e r n a t i v e p a t t e r n s of f r a m e m o u n t i n g s have b e e n suggested for fixation of pelvic fractures [2, 8], b u t these o f t e n m a k e the p o s t o p e r a t i v e n u r s i n g of associated surgical c o n d i t i o n s difficult. W e f o u n d that the use of c o m p l i c a t e d e q u i p m e n t was u n n e c e s s a r y
188 because the position could be a d e q u a t e l y maintained with one single tie bar. The technique allowed easy handling, turning and lifting of the patient so that nursing care was facilitated in c o m p a r i s o n with sling suspension [7]. In very y o u n g patients there m a y be a risk of d a m a g i n g the apophyseal plate of the iliac crest and our y o u n g e s t patient, 14 years old, later developed an exostosis on the iliac crest which required surgical removal. T h r e e other patients were 15 and 17 years old at the time of the accident and suffered no complication f r o m this cause. In five cases the patients were mobilised before the r e m o v a l of the H o f f m a n n apparatus, but most of the patients h a d multiple injuries which p r e v e n t e d mobilisation on crutches before six weeks although they were allowed to m o v e freely in bed w h e n e v e r possible. Prior to 1972, at our clinic, internal fixation of the pelvis was carried out with A O plates and screws, especially in patients with severe bleeding [5]. Alt h o u g h this m e t h o d is still used in similar cases we n o w regard the H o f f m a n n external fixator as preferable whenever, it "is indicated, and it has b e c o m e the
E. B. Riska et al.: External Fixation of Unstable Pelvic Fractures routine m e t h o d in our clinic. The technique is simple and can be carried out as an e m e r g e n c y p r o c e d u r e even at night.
References 1. Adrey, J.: Hoffmann's external anchorage coupled in frame arrangement. Paris: Gead 1971 2. Carabalona, P., Rabichong, P., Bonnel, F., Perruchon, E., Peguret, F.: Contribution of the external fixation in disjunctions of the pubis and of the sacroiliac articulation. Montpellier-Chirurgica119, 61-70 (1973) 3. Connes, D'Henry: Hoffmann's double frame external anchorage. Methods, applications and results in 16 observations. Paris: Gead 1973 4. Hoffmann, R.: Osteotaxis, guide technique et clinique. Courrier de la c6te, S. A. Nyon 1961 5. Riska, E. B., Lyytik/iinen, M.: Operatively treated pelvic fractures in 26 patients with multiple injuries. Acta Orthop. Scand. 44, 119-120 (1973) 6. Riska, E. B., von Bonsdorff, H., Hakkinen, S., Jaroma, H., Kiviluoto, O., Paavilainen, T.: Primary operative fixation of long bone fractures in patients with multiple injuries. J. Trauma 17, 111-121 (1977) 7. Schweiberer, L.: Beckenbriiche. Chirurg 41, 55-62 (1970) 8. Slfitis, P., Karaharju, O.: External fixation of the pelvic girdle with a trapezoid compression frame. Injury 7, 53-56 (1975)
