Operative Fixation of Unstable Pelvic Ring Injuries in Polytrauma Patients S. J. O'Flanagau, G. Fulton, J. O'Beirne, J. P. MeEhvain
Departmentof OrthopaedicSurgery,Meath Hospital,Dublin, Summary Sixteen polytraumatizedpatients with a variety of unstable pelvic ring fractures were treated With ope(ative fixation. We have foundthat an aggressive approachwith adequateearly stabilizationof the l~elvisoffersmanyadvantagesover conservativemanagementparticularlyin polytraumatizedpatients, Introduction There has been increased awareness recently of the clinical problems associatedwith unstable pelvic ring injuries'.2. These affect the outcome of the patient both in the short and long term. This has led to the identification of individual fracture types and treatment regimens have been proposed in order to improve outcomes. The basis of treatment is adequate stabilization of the pelvis in any patient who has an unstable pelvic ring; this being described as a ring which cannot withstand normal physiological forces without deformation. This paper outlines our early experience in the operative stabilization of these injuries in the multiple trauma patient. Patients From Jan. 1986 to Jan. 1990,16 patients had stabilization of an unstable pelvic fracture in this unit. There were 11 females and 5 males with an age range of 12-72 years (mean : 37) These injuries occurred in polytmumatized patients (Table I) and all were caused by high velocity injuries, 14 being victims of road traffic accidents. Definitive treatment of the ring disruption was deferred until the patient was resuscitated and physiologically stabilized. In some instances, temporary stabilization of the pelvic ring was employed during initial management. Prior to definitive treatment, fall assessment of pelvic stability was carried out. This was performed using clinical and rathographic criteria. Clinical assessmentofthedisruption included examination of the ring withthe patient under anaesthetic prior to surge~. Radiographic assessment consisted of plain x-rays of the pelvis (AP, inlet and outlet views) and CT examination of the ring, the latter being particularly useful when assessing the posterior ~cro-iliae joint complex (Fig. 1). Pelvic disruptions were classified according to Tile4(Table II). This classification emphasizes whether the ring shows rotational instability (e,g. lateral compression or open book
Fig. 1 - CT of pelvisshowingthe posteriorelements,clearly showsfractureof sacrumalongwithdamageto both S/I joints,not appreciatedon plainfilms, injuries) or injuries which are unstable beth rotationally and vertically. Table 11I shows the different types of disruptions treated in this series.
Treatment Five patients had temporary reduction of the pelvic disruption using an external fixator during initial management in the resuscitative phase prior to full assessmentof the pelvic ring. The 5 injuries which displayed rotational injury alone were treated with anterior stabilization using an external fixator in 3 cases and plate fixation of the symphysis pubis in 2. htjuries fl~atwere rotationally and vertically unstable were treated with combined anterior and posterior fixation with the exception of one. Anterior fixation was obtained, as in the rotationally unstable injuries by using either external fixation or plate fixation depending on the anatomy of the disruption. Twelve posterior stabilization procedures were required in these 11 patients one having a bilateral sacroiliac disruption.
TABLEI INJURIESASSOCIATEDWITH PELVICDISRUViZON Addressfor correspondence: S. J. O'Flanagan, 12, Sion Hill Avenue, Harold'sCross,Dublin6.
Other Gu tract skeletal injuries injuries PatientsNo.
9
4
Head injury Ruptured with LOC abdominal viscera 3
2
Significant chestinjury 2
Peripheral n.erve mjury 1
I.LM.S. FeSru~U,1992
40 Flanagan et al. TABLE H
When sacralbars were used,they were inserted through the lilac crest adjacent to the posterior superior iliac spine and passed transversely superficial to the sacrum to enter the opposite lilac crest in the same positions.
TILECLASSIFICATION Classificationof pelvicdiarup6.on Type A
TypeB
TypeC
Tile M
Stable At - Fracturesof the pelvis'notinvolvingthe ring A2- Stable,minimallydisplacedfracturesof the ring Rotationallyunstable,verticallystable B1- Openbook B2- Lateralcompression:ipallateral B3 - La~al compression:contralatcral (buckethandle) Rotafionallyand verticallyunstable Ci- Unilateral C2- Bilateral C3- Associatedwithan acetabutarfracture J]3JS7ll-B 1988 TABLE m TYPE OF PELVICDISRUPTION
Rotationallyunstable: B1 3 B2 1 B3 1 Verticallyand rotationallyunstable: C1 5 C2 1 C3 5
5
11
The procedures utilized were the insertion of sacral bars in 2 cases, plating of the sacroiliacjoint in 4 cases and plating of the ilium in 6 eases (Fig. 2). Definitive stabilization was performed on average 8 days post injury. The time delay to fixation depended on many factors including time taken to transfer patient to this unit and the severity of associated injuries.
Results The patients were reviewed 6-58 months following stabilization with a mean of 28 months. The following aspects were assessed: (1) Restoration of stability of the pelvic ring; (2) Ability of the patient to return to theirpre-morbidactivity level; (3) The presence of pain and (4) The presence of any residual deformity. At review, the pelvic ring was united in all cases. Partial loss of fixation occurredin 1patient whichdelayed union, but union did occur. Ten patients (62%) were both pain free and had returned to their previous level of activity. Fourpatients continue to have pain located in the area of the sacroiliacjoint, this being bilateral and of moderate intensity in the patient who had severe bilateml di~ption of the sacroiliacjoints (C2 disruption). Two patients had not yet returned to their previous level of activity and itis ~nlikely that they will do so in the future. The reasons for this are multifactori~land do not solely relate te their pelvic disruption which mdibgraphically are satisfactory. Two patients had residual leg length discrepancies one of 2cms and the other had a discrepancy of 3cms, the latter having sustained a tibial fracture on the same side which contributed to the discrepancy.
Complications Three patients developed deep venous thrombosis. Only 1 patient developed ARDS although 50% required ventilation for up to 3 days post-operatively. One patient whose disrupted pubic symphysis was plated immediately following a laparotomy through a midiine incision developeddehiscence of the wound. This healed following resuturing and the symphysis healed uneventfully.
Fixation Techniques In all cases where plating was employed, standard A t plating techniques were used. Externalfixators were appliedusing 5mmpins insertedinto the bone just posterior to the anterior superioriliac spine. We employed a simple A frame configuration.
Pelvic ring disruptions generally occur in polytraumatizcd patients and as such present complex managementproblems. As a result, they have in the past been frequently treated
Fig 2A- Verticalshearinjuryof polviswithposteriordisruption occurringthroughthe iliumand involvingthe S/Ijoint,
Fig 2B - Anatomicalreductionof ring wits doubleplate fixation employedan~riorlyand posteriorly.
Discussion
Vol.161 No.2
Unstablepelvicringinjuriesinpolytraumapatients 41 TABLE IV FIXATION METHODS USED
Type B: 5
Type C: 11 Ant. Stabilizations (1 Case Deferred) Post, Stabilizations (1 Bilateral) ~
External Fixator: Plating Symphyals:
3
External fixator: Ant. Plating:
2 8
Sacral Bar: Plating S/I Joint: Plating Ilium:
2 4 6
2
conservatively leading to inadequate reduction and stabilization of the disruption. This in turn has led to an increase in morbidity for the patient both in the short and long tenn, Recently, numerous authors~,7. have suggested that early definitive operative treatment of fractures can reduce the complication and morbidity rate of patients. This along with the recognition that certain pelvic disruptions are associated with late clinical problems z haS led to more aggressive treatment regimens being introduced to treat these patients. Temporary stabilization of the disrupted pelvis using an external fixator frame is very useful in the resuscitation of polytraumatized patients, as it can significantly decrease ongoing blood loss by decreasing intrapelvic volume and creating a tamponade effect 9. It is useful in the early management of type B and type C disruptions and indeed may be the only stabilization required in some type B injuries, aS demenstrated by 3 cases in this series. Early close liaison between sub-speciality groups within the team managing a multiple traumatized patient is vital. This is of particular relevance when the patient has a disrupted pelvis. Thus exploration of the abdominal cavity or the genito-urinary tract may be combined with internal fixation of the pelvis in a planned sequential manner, This most commonly consists of plate fixation ofa diastasis of the symphysis pubis and in our experience could be done safely without compromising the patient. We would however, advise caution in opening retroperitoneal spaces in the early management of these cases. Once the patient is physiologically stabilized and all immediate treatment has been completed, close attention must bepaid tothe exact anatomy of the disrupted pelvis. C.T, scanning is very helpful in this regard and in our experience demonstrated instability of the pelvis which was not apparent on plain x-ray. In order to mobilize patients early and to improve long term results in these potentially disabling injuries, two criteria must be met. These are anatomical reduction and stable internal fixation. The personality of the rotationally unstable injury dictates what type of anl~rior fixation is used. Consideration
should be given to anterior fixalJon of the pelvis at the time of exploratory surgery of the abdominal cavity when indicated. Combined anterior and posterior stabilization is usually required for vertically unstable fractures. Here again, anterior stabilization is dependent on the personality of the disruption. The preferred operative procedure for disrupted sacro-iliac joints and fractures of the sacrum is plate and screw fixation, as sacral bars give a less satisfactory outcome because of their inherent lack of stability. Despite the extent of injuries sustained by the patients in this group, the level of morbidity waS relatively low. The complication rate was also low and this we attribute to good nursing care significantly facilitaied by early mobilization. Over 60% of oar patients are both pain free and have returned to their pre-morbid level of activity. Ongoing pain, usuMly of mild degree is well recogaised following disruptions of the sucro-iliac joint even after reduction and fixation. Our results compare favourably with the results of series in which patients were treated conservatively ~~ The level of symptoms in the remaining patients, we believe, was miniraised by the stabilisation obtained. In conclusion, we feel that careful delineation of the exact anatomy of a pelvic disruption followed by adequate stabilization of all contributing destabilizing elements, offers patients the best possible outcome from potentially disabling injuries. References
1. Goldstein,A., Phillips,J., Sclafanl,S. J. A., Scala, J,, Duncan,A., Goldstuin,J,, PaneUa,T., Shaftun,G, Earlyopenand inlemaIfixation of the dlsmptedpelvicrang.J. Trauma 1986:26, 325-333. 2, Kellam,J F,, McMun~7,R. Y,, Paley,D,, Tile,M, The unstablepelvic fracture, OperativetreaUaent.Onhop, ClinicsNorth America1987: No. 1, 25-41, 3, 'I'lle,M. FJacturesof the pelvisand acetabulum.Balmnore,Wtll~ams & Williams,1984. 4, Tale,M. Pelvichag fiactures:Shouldtheybe fixed?d. Boneand Joint Surg. 1988:70-B, 1-2. 5. Dabezies,E, I,, Millet,C. W., Murphy,C. P,, Acker,1, H.,Robicheaux, R. E.,D'Ambrosia,R. D. Stabllixationofsacroiliacjointdisruptionwith threadedcoropressionrods. Clin.O~op. 1989:246,165-t71. 6. Johnson, K, D,, Cadambi, A., Seiben, G. B, Incidenceof adult respiratoD,distresssyndrometh patientswithmultiplemuscuinskeletal injuries.Effectof early opetut,vestabiliTanonof fractures.J. Traunla 1985:25, 375-384, 7. Eone,L.B.,Johnson,N.D,,Weigelet,J.Z.,Scheinberg,R. Eadyversus delayedstabilizationd l~moralfractures.A prospectiverandomized study,J. Bc~leand Joint Surg.March 1989:71-A,336-340. 8, Chapman,M. W. Multiple-injuredpattern.Instructionalcourse1eclure 212. Readat the AnnualMeEtingof the AmertuanAcademyof OrthopaedicSurgeons,Las Vegas,Nevada, 1989, 9. S/arts,P, Karaharju,E. O. Externalfixationof unstablepelvicfractures, Experiencein 22 patientstreated with a trapezoidcompression frame. Cbn. Orthop. 1989:1511,73-81. 10. Holdswo~h,F.W. Fracture- dislocationof the pelvis.J Boneand JointSurg 1948:30B, 461-466 11. Semba,R. 31, Yasukawa,K., (instiin,R. B. Cnticalanalysisof results of 53 malgaignefracturesot the pcl'ds.J. Trauma 1983:23,535-537.
Departmentof OrthopaedicSurgery,Meath Hospital,Dublin, Summary Sixteen polytraumatizedpatients with a variety of unstable pelvic ring fractures were treated With ope(ative fixation. We have foundthat an aggressive approachwith adequateearly stabilizationof the l~elvisoffersmanyadvantagesover conservativemanagementparticularlyin polytraumatizedpatients, Introduction There has been increased awareness recently of the clinical problems associatedwith unstable pelvic ring injuries'.2. These affect the outcome of the patient both in the short and long term. This has led to the identification of individual fracture types and treatment regimens have been proposed in order to improve outcomes. The basis of treatment is adequate stabilization of the pelvis in any patient who has an unstable pelvic ring; this being described as a ring which cannot withstand normal physiological forces without deformation. This paper outlines our early experience in the operative stabilization of these injuries in the multiple trauma patient. Patients From Jan. 1986 to Jan. 1990,16 patients had stabilization of an unstable pelvic fracture in this unit. There were 11 females and 5 males with an age range of 12-72 years (mean : 37) These injuries occurred in polytmumatized patients (Table I) and all were caused by high velocity injuries, 14 being victims of road traffic accidents. Definitive treatment of the ring disruption was deferred until the patient was resuscitated and physiologically stabilized. In some instances, temporary stabilization of the pelvic ring was employed during initial management. Prior to definitive treatment, fall assessment of pelvic stability was carried out. This was performed using clinical and rathographic criteria. Clinical assessmentofthedisruption included examination of the ring withthe patient under anaesthetic prior to surge~. Radiographic assessment consisted of plain x-rays of the pelvis (AP, inlet and outlet views) and CT examination of the ring, the latter being particularly useful when assessing the posterior ~cro-iliae joint complex (Fig. 1). Pelvic disruptions were classified according to Tile4(Table II). This classification emphasizes whether the ring shows rotational instability (e,g. lateral compression or open book
Fig. 1 - CT of pelvisshowingthe posteriorelements,clearly showsfractureof sacrumalongwithdamageto both S/I joints,not appreciatedon plainfilms, injuries) or injuries which are unstable beth rotationally and vertically. Table 11I shows the different types of disruptions treated in this series.
Treatment Five patients had temporary reduction of the pelvic disruption using an external fixator during initial management in the resuscitative phase prior to full assessmentof the pelvic ring. The 5 injuries which displayed rotational injury alone were treated with anterior stabilization using an external fixator in 3 cases and plate fixation of the symphysis pubis in 2. htjuries fl~atwere rotationally and vertically unstable were treated with combined anterior and posterior fixation with the exception of one. Anterior fixation was obtained, as in the rotationally unstable injuries by using either external fixation or plate fixation depending on the anatomy of the disruption. Twelve posterior stabilization procedures were required in these 11 patients one having a bilateral sacroiliac disruption.
TABLEI INJURIESASSOCIATEDWITH PELVICDISRUViZON Addressfor correspondence: S. J. O'Flanagan, 12, Sion Hill Avenue, Harold'sCross,Dublin6.
Other Gu tract skeletal injuries injuries PatientsNo.
9
4
Head injury Ruptured with LOC abdominal viscera 3
2
Significant chestinjury 2
Peripheral n.erve mjury 1
I.LM.S. FeSru~U,1992
40 Flanagan et al. TABLE H
When sacralbars were used,they were inserted through the lilac crest adjacent to the posterior superior iliac spine and passed transversely superficial to the sacrum to enter the opposite lilac crest in the same positions.
TILECLASSIFICATION Classificationof pelvicdiarup6.on Type A
TypeB
TypeC
Tile M
Stable At - Fracturesof the pelvis'notinvolvingthe ring A2- Stable,minimallydisplacedfracturesof the ring Rotationallyunstable,verticallystable B1- Openbook B2- Lateralcompression:ipallateral B3 - La~al compression:contralatcral (buckethandle) Rotafionallyand verticallyunstable Ci- Unilateral C2- Bilateral C3- Associatedwithan acetabutarfracture J]3JS7ll-B 1988 TABLE m TYPE OF PELVICDISRUPTION
Rotationallyunstable: B1 3 B2 1 B3 1 Verticallyand rotationallyunstable: C1 5 C2 1 C3 5
5
11
The procedures utilized were the insertion of sacral bars in 2 cases, plating of the sacroiliacjoint in 4 cases and plating of the ilium in 6 eases (Fig. 2). Definitive stabilization was performed on average 8 days post injury. The time delay to fixation depended on many factors including time taken to transfer patient to this unit and the severity of associated injuries.
Results The patients were reviewed 6-58 months following stabilization with a mean of 28 months. The following aspects were assessed: (1) Restoration of stability of the pelvic ring; (2) Ability of the patient to return to theirpre-morbidactivity level; (3) The presence of pain and (4) The presence of any residual deformity. At review, the pelvic ring was united in all cases. Partial loss of fixation occurredin 1patient whichdelayed union, but union did occur. Ten patients (62%) were both pain free and had returned to their previous level of activity. Fourpatients continue to have pain located in the area of the sacroiliacjoint, this being bilateral and of moderate intensity in the patient who had severe bilateml di~ption of the sacroiliacjoints (C2 disruption). Two patients had not yet returned to their previous level of activity and itis ~nlikely that they will do so in the future. The reasons for this are multifactori~land do not solely relate te their pelvic disruption which mdibgraphically are satisfactory. Two patients had residual leg length discrepancies one of 2cms and the other had a discrepancy of 3cms, the latter having sustained a tibial fracture on the same side which contributed to the discrepancy.
Complications Three patients developed deep venous thrombosis. Only 1 patient developed ARDS although 50% required ventilation for up to 3 days post-operatively. One patient whose disrupted pubic symphysis was plated immediately following a laparotomy through a midiine incision developeddehiscence of the wound. This healed following resuturing and the symphysis healed uneventfully.
Fixation Techniques In all cases where plating was employed, standard A t plating techniques were used. Externalfixators were appliedusing 5mmpins insertedinto the bone just posterior to the anterior superioriliac spine. We employed a simple A frame configuration.
Pelvic ring disruptions generally occur in polytraumatizcd patients and as such present complex managementproblems. As a result, they have in the past been frequently treated
Fig 2A- Verticalshearinjuryof polviswithposteriordisruption occurringthroughthe iliumand involvingthe S/Ijoint,
Fig 2B - Anatomicalreductionof ring wits doubleplate fixation employedan~riorlyand posteriorly.
Discussion
Vol.161 No.2
Unstablepelvicringinjuriesinpolytraumapatients 41 TABLE IV FIXATION METHODS USED
Type B: 5
Type C: 11 Ant. Stabilizations (1 Case Deferred) Post, Stabilizations (1 Bilateral) ~
External Fixator: Plating Symphyals:
3
External fixator: Ant. Plating:
2 8
Sacral Bar: Plating S/I Joint: Plating Ilium:
2 4 6
2
conservatively leading to inadequate reduction and stabilization of the disruption. This in turn has led to an increase in morbidity for the patient both in the short and long tenn, Recently, numerous authors~,7. have suggested that early definitive operative treatment of fractures can reduce the complication and morbidity rate of patients. This along with the recognition that certain pelvic disruptions are associated with late clinical problems z haS led to more aggressive treatment regimens being introduced to treat these patients. Temporary stabilization of the disrupted pelvis using an external fixator frame is very useful in the resuscitation of polytraumatized patients, as it can significantly decrease ongoing blood loss by decreasing intrapelvic volume and creating a tamponade effect 9. It is useful in the early management of type B and type C disruptions and indeed may be the only stabilization required in some type B injuries, aS demenstrated by 3 cases in this series. Early close liaison between sub-speciality groups within the team managing a multiple traumatized patient is vital. This is of particular relevance when the patient has a disrupted pelvis. Thus exploration of the abdominal cavity or the genito-urinary tract may be combined with internal fixation of the pelvis in a planned sequential manner, This most commonly consists of plate fixation ofa diastasis of the symphysis pubis and in our experience could be done safely without compromising the patient. We would however, advise caution in opening retroperitoneal spaces in the early management of these cases. Once the patient is physiologically stabilized and all immediate treatment has been completed, close attention must bepaid tothe exact anatomy of the disrupted pelvis. C.T, scanning is very helpful in this regard and in our experience demonstrated instability of the pelvis which was not apparent on plain x-ray. In order to mobilize patients early and to improve long term results in these potentially disabling injuries, two criteria must be met. These are anatomical reduction and stable internal fixation. The personality of the rotationally unstable injury dictates what type of anl~rior fixation is used. Consideration
should be given to anterior fixalJon of the pelvis at the time of exploratory surgery of the abdominal cavity when indicated. Combined anterior and posterior stabilization is usually required for vertically unstable fractures. Here again, anterior stabilization is dependent on the personality of the disruption. The preferred operative procedure for disrupted sacro-iliac joints and fractures of the sacrum is plate and screw fixation, as sacral bars give a less satisfactory outcome because of their inherent lack of stability. Despite the extent of injuries sustained by the patients in this group, the level of morbidity waS relatively low. The complication rate was also low and this we attribute to good nursing care significantly facilitaied by early mobilization. Over 60% of oar patients are both pain free and have returned to their pre-morbid level of activity. Ongoing pain, usuMly of mild degree is well recogaised following disruptions of the sucro-iliac joint even after reduction and fixation. Our results compare favourably with the results of series in which patients were treated conservatively ~~ The level of symptoms in the remaining patients, we believe, was miniraised by the stabilisation obtained. In conclusion, we feel that careful delineation of the exact anatomy of a pelvic disruption followed by adequate stabilization of all contributing destabilizing elements, offers patients the best possible outcome from potentially disabling injuries. References
1. Goldstein,A., Phillips,J., Sclafanl,S. J. A., Scala, J,, Duncan,A., Goldstuin,J,, PaneUa,T., Shaftun,G, Earlyopenand inlemaIfixation of the dlsmptedpelvicrang.J. Trauma 1986:26, 325-333. 2, Kellam,J F,, McMun~7,R. Y,, Paley,D,, Tile,M, The unstablepelvic fracture, OperativetreaUaent.Onhop, ClinicsNorth America1987: No. 1, 25-41, 3, 'I'lle,M. FJacturesof the pelvisand acetabulum.Balmnore,Wtll~ams & Williams,1984. 4, Tale,M. Pelvichag fiactures:Shouldtheybe fixed?d. Boneand Joint Surg. 1988:70-B, 1-2. 5. Dabezies,E, I,, Millet,C. W., Murphy,C. P,, Acker,1, H.,Robicheaux, R. E.,D'Ambrosia,R. D. Stabllixationofsacroiliacjointdisruptionwith threadedcoropressionrods. Clin.O~op. 1989:246,165-t71. 6. Johnson, K, D,, Cadambi, A., Seiben, G. B, Incidenceof adult respiratoD,distresssyndrometh patientswithmultiplemuscuinskeletal injuries.Effectof early opetut,vestabiliTanonof fractures.J. Traunla 1985:25, 375-384, 7. Eone,L.B.,Johnson,N.D,,Weigelet,J.Z.,Scheinberg,R. Eadyversus delayedstabilizationd l~moralfractures.A prospectiverandomized study,J. Bc~leand Joint Surg.March 1989:71-A,336-340. 8, Chapman,M. W. Multiple-injuredpattern.Instructionalcourse1eclure 212. Readat the AnnualMeEtingof the AmertuanAcademyof OrthopaedicSurgeons,Las Vegas,Nevada, 1989, 9. S/arts,P, Karaharju,E. O. Externalfixationof unstablepelvicfractures, Experiencein 22 patientstreated with a trapezoidcompression frame. Cbn. Orthop. 1989:1511,73-81. 10. Holdswo~h,F.W. Fracture- dislocationof the pelvis.J Boneand JointSurg 1948:30B, 461-466 11. Semba,R. 31, Yasukawa,K., (instiin,R. B. Cnticalanalysisof results of 53 malgaignefracturesot the pcl'ds.J. Trauma 1983:23,535-537.
