Injury (1992) 23, Cl), 31-37
Operative
Prinledin Great Britain
31
treatment of unstable pelvic fractures
K. S. Leung, P. Chien, W. Y. Shen and W. S. So The Chinese University
of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
Unstable pelvic fractures are serious injuries. Non-operative treatment gives poor e&y and late results. We report the results of operative treatment of 28 unstable pelvic fmctures: eight were rotatory unstable and 20 were both rotatory and vertically unstable. The average age of the patients was 33 years. All the patients underwent operafion according to a definite protocol for inter& fix&on. Mobilization was started within 2 weeks after the operation: Ihe average hospital stay was 9.8 weeks. With an average follow-up of 19 months. there was no mortality. In 20patients there ulas no discomfort, five patients had moderate back pain and four patients walked with a limp due to leg length inequality and back pain. Twenty patients returned to gain@ employment. Complications included one deep zoound infection, fzuo superfirial wound infections, one dislodgement of the external jixator, and residual interal rotatoy deformity of the hemipelvis. We conclude that opertive treatment of unstable pelvic fmctures is sfe and that the early and late results are much better thun those treated by non-operative means.
Introduction Unstable pelvic fractures (Kellam et al., 1987; Tile, 1988) are caused by high energy trauma. They are often associated with other injuries (Huittinen and Skis, 1972; Looser and Crombie, 1976; Naam et al., 1983). Conventional methods of treatment of these fractures give poor results (Holdsworth, 1948; Raf, 1966: Skis and Huittinen, 1972; Semba et al., 1983; Henderson, 1989) due to difficulty in obtaining reduction and fixation of the fractures. Morbidity and mortality are further increased because of the need for prolonged traction and bed rest (Hesp et al., 1985). With increasing awareness of the late complications of unstable pelvic fractures treated non-operatively (Monahan and Taylor, 1975; Tile et al., 1982; Semba et al., 1983; Henderson, 1989) and better understanding of the pathology and biomechanics of the fracture-dislocations (Bucholz, 1981; Tile, 1984), operative treatment for these groups of fractures may provide a better alternative. This paper reports the results of operative treatment of 28 unstable pelvic fractures.
Patients A total of 182 patients with pelvic fractures were admitted to our unit during a period from June 1984 to December 1988. Of these patients, 34 (16.7 per cent) had unstable pelvic fractures. Two of these patients died during exploraSC,1992 Butterworth-Heinemann 0020-1383/92/010031-07
Ltd
Table I. Classification of pelvic fractures according to Tile’s
classification Type A Al A2
Stable Fractures of the pelvis not involving the ring Stable, minimally displaced fractures of the ring
Type B Bl 82 83
Rotationally unstable, vertically stable Open book Lateral compression: ipsilateral Lateral compression: contralateral (bucket handle)
Type C Cl c2 c3
Rotationally and vertically unstable Unilateral Bilateral Associated with an acetabular fracture
3
16 3 2 Total
28
tory laparotomy for intra-abdominal bleeding before the fractures could be fixed. Of the 32 patients with unstable fractures who were operated on, 28 patients were assessed. The other four patients were not assessed because the follow-up time was shorter than 1 year. There were six females and 22 males. Their ages ranged from 23 to 57 years, with an average of 33 years. A total of 21 fractures were caused by road accidents. Five resulted from falls from a height and two from crushing injuries by heavy objects. All but one were multiply-injured. The Injury Severity Score (KS) ranged from 9 to 66 with an average of 43.
Fractures The fractures were classified according to Tile’s classification (Tile, 1988) (7iibL I). Two patients (figure la) had diastasis of the pubic symphysis with separation of more than 2.5 cm and gaping of the anterior part on both sacro-iliac joints (Bl, stage 3). Two patients (Figure 2) had ipsilateral compression double fractures (B2). Three patients (Figure 3) had a buckethandle type of fracture (B3). Of the 16 Cl fractures, 10 (Figure &) were a Malgaigne type of fracture-dislocation; six (Figure5a) had a fracture through the sacrum with vertical displacement. Three patients (Figure 6) had bilateral fracturedislocations (C2) and two patients (Figure 7n) had a fracture of the ipsilateral acetabulum (0).
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
32
Figure 1. a, Radiograph showing type B1 stage three disruption of the pelvic ring. b, Postoperative pubic symphysis with two dynamic compression plates at right-angles to each other.
Figure 2. Radiograph double fractures.
showing
radiograph
1
showing the fixation of the
type B2 ipsilateral compression
Figure 3. Radiograph showing pression double fractures.
type
Figured. a, Preoperative radiograph showing the unilateral dislocation of sacro-iliac joints and diastasis b, Postoperative radiograph showing the well-reduced and fixed dislocations.
B3 contralateral
com-
of the pubic symphysis.
Leung et al.: Operative treatment of unstable pelvic fractures
Figure 5. a, Preoperative radiograph showing fracture of the sacral ala and diastasis of the pubic symphysis. showing the fixation of the posterior fracture with sacral rods and diastasis with plates.
b, Postoperative
radiograph
and iliac oblique views were done. Vertical displacement was treated with temporary skeletal traction via a tibia1 Steinmann pin. Operation was carried out once the condition of the patient was stabilized. Pelvic and other fractures were fixed in the same session. Operative
Figure 6. Radiograph iliac joints.
showing
bilateral dislocation
of the sacro-
There was one open fracture. Three patients had a neurological deficit involving the L5 root, and one patient had double incontinence due to sacral plexus injury.
Method All patients were assessed and resuscitated in the Accident and Emergency Department. Standard X-ray films which included the anteroposterior, inlet, outlet, obturator oblique
Figure 7. a, Preoperative
management
Diastasis of the pubic symphysis was reduced through a Pfannensteil incision and fixed with two plates; one on the superior and one on anterior or posterior surfaces of the pubic symphysis (Figure Ib). Fractures in the anterior pubic rami were treated according to the fracture patterns. Open reduction and plating through an ilio-inguinal incision was carried out for a 8b). fracture involving unilateral pubic rami (F@res8u, External fixation with a Sl;itis frame configuration was employed in patients with multiple fractures (Figwe 9a) and patients with bilateral pubic rami fractures (Figuregb) in order to achieve stability with minimal surgical trauma. Dislocations of the sacro-iliac joints were reduced through a retroperitoneal approach and fixed with two two-hole Dynamic Compression Plates (DCPs) (figures 4b. 8b). Concomitant acetabular hactures were also fixed at the same time (Figure 7b). Posterior fractures through the sacrum were reduced with posterior incisions and fixed with two Harrington threaded sacral rods (Figure sb).
radiograph showing pelvic disruption associated with acetabular ‘fractures’ - type 0. b, Postoperative radiograph showing internal fixation of the pelvic and acetabular fractures through simultaneous Kocher-Langenbeck and ilio-inguinal
incisions.
34
injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
1
Figure 8. a, Preoperative radiograph showing dislocation of the sacro-iliac joint, diastasis of the pubic symphysis and contralateral pubic fractures. There was a concomitant posterior fracture-dislocation of the ipsilateral hip. b, Postoperative radiograph showing rctropcritoneal plating of the sacro-iliac joint and anterior plating of the pubic symphysis and contralateral pubic ramus fracture. The hip was also reduced.
rami
Figure9. a, Postoperative radiograph of a patient with a Malgaigne fracture and bilateral femoral fractures. The pelvic fracture was stabilized with sacral bars posteriorly and external fixator of a Skis frame anteriorly. The femoral fractures were fixed with intramedullary nails during the same operative session. b, Postoperative radiograph showing fracture of the sacral ala and bilateral pubic rami fracture fixed with sacral bars and external fixator (which was removed). Note the residual internal rotation deformity of the involved hemipelvis in both patients.
I ________I_
Figure 10. Measurement view of the pelvis.
of posterior
displacement
of an inlet
Figure 11. Measurement outlet view of the pelvis.
of the vertical
displacement
on an
Leung et al.: Operative treatment of unstable pelvic fractures
Postoperative management The patients were allowed to sit out of bed as soon as possible. Non-weight-bearing walking was started as soon as the physical condition of the patient allowed. Graduated weight-bearing walking was started 6-8 weeks later, when the anterior external fixator was also removed if one was used. Full weight-bearing walking was started in 10-12 weeks. Assessment The functional outcome and the incidence of back pain, gait and limb length discrepancy were assessed. Radiological assessment was with plain radiographs. A review of the literature provided no suggestions as to a suitable method for quantifying the displacement. The following method was adopted in our assessment: the inlet view shows the posterior displacement (Figure 10). A vertical line was drawn along the midline of the lumbar spines. Horizontal lines were drawn perpendicular to this central line tangential to the posterior crests and the distance between these two lines was noted. The outlet view shows the vertical displacement (Figure II). Similar measurements were used to assess the vertical displacement. The displacement was judged to be none, slight ( < 1 cm) or severe ( > I cm). For the rotational deformity, both the inlet and the anteroposterior views had to be used to judge the asymmetry of the hemipelvis. Quantification in this situation was difficult and not accurate. Therefore only the direction of the rotational displacement was noted.
Results The time between admission and operation ranged from 4 h to 5 days with an average of 2.5 days. The operative procedures are summarized in Tiblell. A total of 15 posterior fracture-dislocations were fixed with parallel Harriligton sacral rods; 10 were fixed with two two-hole 4.5 Dynamic compression plates; one was fixed with two cancellous screws transfixing the sacro-iliac joints from the posterior ilium. Half of the anterior fractures were fixed with external fixators in the configuration of a S&is frame. The other half were fixed internally with plates. The operative time for fixing the pelvic fractures ranged from 2 to 4.5 h with an average of 3.2 h. Postoperatively, the duration of immobilization ranged from 3 to 14 days with an average of 7 days. The duration of non-weight-bearing walking ranged from 3 to 6 weeks with an average of 4.8 weeks. The duration of full weight-bearing walking ranged from 8 to 14 weeks with an average of 11.5 weeks. The duration of hospital stay ranged from 4 to 16 weeks with an average of 9.8 weeks. The average period of sick leave required was 6.5 months. The early morbidities are shown in TableIll. Six patients with an external fixator for the anterior fractures had minor pin tract discharge; two of them had a positive bacteriological culture. All except one subsided with simple local treatment. The patient in whom the local treatment failed was doubly incontinent and had a urinary tract infection. The infection subsequently spread to the hip joint which eventually fused. One patient had the external fixator dislodged at the end of the 4th week after the operation. He was confined to bed tor 2 more weeks before further ambulation. Two patients with sacral rod fixation of the posterior fractures developed superficial wound infection which subsided after non-operative treatment.
35
Late sequelae The patients were assessed with a minimum follow-up period of 12 months. The follow-up period ranged from 12 to 46 months, with an average of 19 months. The late results are shown in Table IV. Twenty (71.4 per cent) patients claimed to have no discomfort. Back pain. Five (17.8 per cent) of patients had moderate back pain that required occasional analgesics. All of these patients had sacral bar fixation for posterior fracturedislocations. As for the anterior fixation method, three of them were fixed with the external fixators and the rest were fixed with plates. Radiologically, two of these patients had residual internal rotation; one had internal rotation and vertical displacement of less than 1 cm. The rest had no demonstrable pelvic deformity on radiographic measurements. Neurological deficit. Of the three patients with neurological complications, one had partial sensory recovery. The other two showed neither deterioration nor recovery. One patient with double incontinence had return of bowel control. Two patients complained of prominence of the ends of the sacral rods in the posterior wound. Four patients walked with a limp. Two of these patients had back pain with pelvic asymmetry and leg length discrepancy of 15 mm. The patient with hip fusion due to infection had a 25 mm leg length discrepancy. One female patient delivered a baby by Caesarean section 3 years after the operation on the pelvis. A total of 20 (71.4 per cent) patients returned to work. Of these, 13 returned to their previous jobs and seven changed
Table IL List of operative procedures performed Procedure
No. of patients
Anterior Plating External fixator
14 14
Posterior Sacral rods Two-hole DCP Screws
15 10 1
Table III. List- of early complications Complication Pin tract discharge Pin tract infection Dislodged external fixator Superficial wound infection
No. of patients 2 2 1 2
Table IV. Incidence of late sequelae No complaints Back pain Neurological deficit Prominence of ends of the sacral rods Limping gait Leg length discrepancy 25mm
20 &2) 2 2 2 2
36
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
to more sedentary
work. Three patients did not resume working because of residual back pain and injuries to other systems. The remaining five patients did not work for reasons unconnected with the pelvic injury. Radiologically, there was no non-union of the fractures. The position of the reduced sacro-iliac joints remained unchanged compared with the immediate postoperative films. There were seven patients with residual internal rotation of the hemipelvis. Of these seven patients, three had less than I cm residual vertical displacement of the hemipelvis but no posterior displacement. All of these patients had sacral bar fixation of the posterior elements (Figures 9a,b). Six of them had external fixators for the anterior fractures and one had plating for the anterior fracture. Patients with retroperitoneal plating of the sacroiliac joints had minimal residual deformity of the hemipelvis.
1
fixation into the first sacral body may be an alternative to extensive bilateral retroperitoneal exposure for plating (Matta and Saucedo, 1989). Harrington sacral bar fixation is one method of achieving quick fixation and good stability (Shaw et al., 1985) provided that the problem of internal rotation of the hemipelvis is taken into consideration. For the anterior fractures, open reduction and plating was also better accepted by the patient and the complications were minimal (Figures 5b, Sb). However, in bilateral pubic fractures or multiple injuries (Fi’res 9a, gb), anterior external fixation might be preferred to achieve anterior stability with minimal surgical trauma. In these cases, intraoperative radiographic screening should be employed to check internal rotational deformity of the hemipelvis due to excessive compression.
Conclusion Discussion Unstable pelvic fractures are serious injuries with important mortality and morbidity (Hesp et al., 1985; Moreno et al., 1986). Non-operative treatment was most popular, but was associated with the disadvantages of prolonged traction in bed, difficult nursing and discomfort. Moreover, late complications included a high incidence of back pain, limping and leg length discrepancy due to malunion (Raf, 1966; Slitis and Huittinen, 1972; Semba et al., 1983; Henderson, 1989). With the modem concept of treating fractures and multiplyinjured patients, attention is drawn to the early operative stabilization of unstable pelvic fractures (Hesp et al., 1985; Goldstein et al., 1986). In this study, there was no operative mortality. Average duration of the operation was 3.2 h. Our patients could be mobilized much earlier despite the multiple injuries. As a result, the duration of hospital stay was much shortened. Complications were minimal, and consisted mainly of minor pin tract discharges and superficial infections of the posterior wounds in patients who had anterior external fixation combined with posterior sacral bar fixation. The case of septic arthritis of the hip probably resulted from bacteraemia arising from urinary tract infection. Functional recovery was excellent. There was minimal leg length discrepancy and gait disturbance. A total of 20 patients (71.4 per cent) resumed work. One patient delivered a baby by Caesarean section 3 years after the injury. The late results were also encouraging. Five patients (17.8 per cent) had residual back pain and required occasional analgesics. This is considerably lower than that reported for non-operative treatment (Raf, 1966; Slatis and Huittinen, 1972; Semba et al., 1983; Henderson, 1989). For the choice of operative treatment, it has been shown in this study that most of the complications were from the external fixator and the sacral bar fixation. In fact, five of the seven patients who had external fixation combined with posterior sacral bar fixation had residual internal rotational deformity and residual back pain. The reasons for these were the excessive compression by the external fixator and the difficulties associated with reduction of the sacro-iliac complex from a posterior approach. There were no complications from plating the sacro-iliac joints and the anterior fractures. The retroperitoneal approach provided direct exposure of the sacro-iliac joint and hence allowed accurate reduction and effective fusion by plating (Simpson et al., 1987). However, decompression of the retroperitoneal haematoma may risk disturbing the tamponade effect and is therefore not recommended within the first 48 h. In bilateral sacro-iliac fractures or dislocations, posterior transiliac screw
Unstable pelvic fractures are results of high-energy injury. Their frequent association with injuries in other systems makes early stabilization preferable in treating these multiply-injured patients. Our analysis of 28 patients treated with operative stabilization for unstable pelvic fractures shows that the operation is safe. Both early and late results are better than those treated by non-operative means.
References Bucholz R. W. (1981)The pathological
anatomy of Malgaigne fracture-dislocations of the pelvis. 1. Bone joint .%rg 63A, 400. Goldstein A., Phillips T., Sclafani S. J. A. et al. (1986) Early open reduction and internal fixation of the disrupted pelvic ring. 1. Trama 26, 325. Henderson R. C. (1989) The long-term results of nonoperatively treated major pelvic disruptions. I. O&up. Trauma 3, 41. Hesp W. L. E. M., Van der Werken C., Keunen R. W. M. et al. (1985) Unstable fractures and dislocations of the pelvic ring results of treatment in relation to the severity of injury. Nefh. J Surg. 37, 148. Holdsworth F. W. (1948) Dislocation and fracture-dislocation of the pelvis. 1. Bone joint Surg. 30B, 461. Huittinen V. M. and Slatis P. (1972) Nerve injury in double vertical pelvic fractures. Acfa. Chir. Scud. 138, 571. Kellam J. F., McMurtry R. Y., Paley D. et al. (1987) The unstable pelvic fracture-operative treatment. Orfhop. Clin. North Am. 18, 25. Looser K. C. and Crombie H. D. (1976) Pelvis fractures: an anatomic guide to severity of injury. Review of 100 cases. Am. J Surg. 132,638. Matta J. M. and Saucedo T. (1989) Internal fixation of pelvic ring fractures. Clin. Orfhop. Rel. Res. 242, 83. Monahan P. R. W. and Taylor R. G. (1975) Dislocation and fracture-dislocation of the pelvis. Injury 6, 325. Moreno C., Moore E. E., Rosenberger A. et al. (1986) Hemorrhage associated with major pelvic fracture: a multispecialty challenge. 1. Traum 26, 987. Naam N. H., Brown W. H., Hurd R. et al. (1983) Major pelvic fractures. Arch. Swg. 118,610. Raf L. (1966) Double vertical fractures of the pelvis. Acfa Chir. Scud. 131,298. Semba R. T., Yasukawa K. and Gustilo R. B. (1983) Critical analysis of results of 53 Malgaigne fractures of the pelvis. 1, Trauma 23, 535.
Leung et al.: Operative treatment of unstable pelvic frachues
Shaw J. A., Mino D. E., Werner F. W. et al. (1985) Posterior stabilisation of pelvic fractures by use of the threaded compression rods - case reports and mechanical testing. Clin. Orthop. Rel. Res. 192, 240. Simpson L. A., Waddell J. P., Leighton R. K. et al. (1987) Anterior approach and stabilization of the disrupted sacroiliac joint. J. Trauma 27, 1332. Slatis P. and Huittinen V. M. (1972) Double vertical fractures of the pelvis. Acfa Chir. Scand. 138, 799. Tile M. (ed.) (1984) Fracfures of the Pelvis and Acefabulum. Baltimore, etc: Williams & Wilkins.
37
Tile M. (1988) Pelvic ring fractures: should they be fixed? J. Bone J&f Surg. 70B, I. Tile M., Lifeso R., Dickinson D. et al. (1982) Disruptions of the pelvic ring. Orfhop. Trans. 6, 324. Paper accepted
28 March
1991.
Requests for reprinfs shouM be addressed to: Dr K. 5. Leung, Senior Lecturer, Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
Operative
Prinledin Great Britain
31
treatment of unstable pelvic fractures
K. S. Leung, P. Chien, W. Y. Shen and W. S. So The Chinese University
of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong
Unstable pelvic fractures are serious injuries. Non-operative treatment gives poor e&y and late results. We report the results of operative treatment of 28 unstable pelvic fmctures: eight were rotatory unstable and 20 were both rotatory and vertically unstable. The average age of the patients was 33 years. All the patients underwent operafion according to a definite protocol for inter& fix&on. Mobilization was started within 2 weeks after the operation: Ihe average hospital stay was 9.8 weeks. With an average follow-up of 19 months. there was no mortality. In 20patients there ulas no discomfort, five patients had moderate back pain and four patients walked with a limp due to leg length inequality and back pain. Twenty patients returned to gain@ employment. Complications included one deep zoound infection, fzuo superfirial wound infections, one dislodgement of the external jixator, and residual interal rotatoy deformity of the hemipelvis. We conclude that opertive treatment of unstable pelvic fmctures is sfe and that the early and late results are much better thun those treated by non-operative means.
Introduction Unstable pelvic fractures (Kellam et al., 1987; Tile, 1988) are caused by high energy trauma. They are often associated with other injuries (Huittinen and Skis, 1972; Looser and Crombie, 1976; Naam et al., 1983). Conventional methods of treatment of these fractures give poor results (Holdsworth, 1948; Raf, 1966: Skis and Huittinen, 1972; Semba et al., 1983; Henderson, 1989) due to difficulty in obtaining reduction and fixation of the fractures. Morbidity and mortality are further increased because of the need for prolonged traction and bed rest (Hesp et al., 1985). With increasing awareness of the late complications of unstable pelvic fractures treated non-operatively (Monahan and Taylor, 1975; Tile et al., 1982; Semba et al., 1983; Henderson, 1989) and better understanding of the pathology and biomechanics of the fracture-dislocations (Bucholz, 1981; Tile, 1984), operative treatment for these groups of fractures may provide a better alternative. This paper reports the results of operative treatment of 28 unstable pelvic fractures.
Patients A total of 182 patients with pelvic fractures were admitted to our unit during a period from June 1984 to December 1988. Of these patients, 34 (16.7 per cent) had unstable pelvic fractures. Two of these patients died during exploraSC,1992 Butterworth-Heinemann 0020-1383/92/010031-07
Ltd
Table I. Classification of pelvic fractures according to Tile’s
classification Type A Al A2
Stable Fractures of the pelvis not involving the ring Stable, minimally displaced fractures of the ring
Type B Bl 82 83
Rotationally unstable, vertically stable Open book Lateral compression: ipsilateral Lateral compression: contralateral (bucket handle)
Type C Cl c2 c3
Rotationally and vertically unstable Unilateral Bilateral Associated with an acetabular fracture
3
16 3 2 Total
28
tory laparotomy for intra-abdominal bleeding before the fractures could be fixed. Of the 32 patients with unstable fractures who were operated on, 28 patients were assessed. The other four patients were not assessed because the follow-up time was shorter than 1 year. There were six females and 22 males. Their ages ranged from 23 to 57 years, with an average of 33 years. A total of 21 fractures were caused by road accidents. Five resulted from falls from a height and two from crushing injuries by heavy objects. All but one were multiply-injured. The Injury Severity Score (KS) ranged from 9 to 66 with an average of 43.
Fractures The fractures were classified according to Tile’s classification (Tile, 1988) (7iibL I). Two patients (figure la) had diastasis of the pubic symphysis with separation of more than 2.5 cm and gaping of the anterior part on both sacro-iliac joints (Bl, stage 3). Two patients (Figure 2) had ipsilateral compression double fractures (B2). Three patients (Figure 3) had a buckethandle type of fracture (B3). Of the 16 Cl fractures, 10 (Figure &) were a Malgaigne type of fracture-dislocation; six (Figure5a) had a fracture through the sacrum with vertical displacement. Three patients (Figure 6) had bilateral fracturedislocations (C2) and two patients (Figure 7n) had a fracture of the ipsilateral acetabulum (0).
Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
32
Figure 1. a, Radiograph showing type B1 stage three disruption of the pelvic ring. b, Postoperative pubic symphysis with two dynamic compression plates at right-angles to each other.
Figure 2. Radiograph double fractures.
showing
radiograph
1
showing the fixation of the
type B2 ipsilateral compression
Figure 3. Radiograph showing pression double fractures.
type
Figured. a, Preoperative radiograph showing the unilateral dislocation of sacro-iliac joints and diastasis b, Postoperative radiograph showing the well-reduced and fixed dislocations.
B3 contralateral
com-
of the pubic symphysis.
Leung et al.: Operative treatment of unstable pelvic fractures
Figure 5. a, Preoperative radiograph showing fracture of the sacral ala and diastasis of the pubic symphysis. showing the fixation of the posterior fracture with sacral rods and diastasis with plates.
b, Postoperative
radiograph
and iliac oblique views were done. Vertical displacement was treated with temporary skeletal traction via a tibia1 Steinmann pin. Operation was carried out once the condition of the patient was stabilized. Pelvic and other fractures were fixed in the same session. Operative
Figure 6. Radiograph iliac joints.
showing
bilateral dislocation
of the sacro-
There was one open fracture. Three patients had a neurological deficit involving the L5 root, and one patient had double incontinence due to sacral plexus injury.
Method All patients were assessed and resuscitated in the Accident and Emergency Department. Standard X-ray films which included the anteroposterior, inlet, outlet, obturator oblique
Figure 7. a, Preoperative
management
Diastasis of the pubic symphysis was reduced through a Pfannensteil incision and fixed with two plates; one on the superior and one on anterior or posterior surfaces of the pubic symphysis (Figure Ib). Fractures in the anterior pubic rami were treated according to the fracture patterns. Open reduction and plating through an ilio-inguinal incision was carried out for a 8b). fracture involving unilateral pubic rami (F@res8u, External fixation with a Sl;itis frame configuration was employed in patients with multiple fractures (Figwe 9a) and patients with bilateral pubic rami fractures (Figuregb) in order to achieve stability with minimal surgical trauma. Dislocations of the sacro-iliac joints were reduced through a retroperitoneal approach and fixed with two two-hole Dynamic Compression Plates (DCPs) (figures 4b. 8b). Concomitant acetabular hactures were also fixed at the same time (Figure 7b). Posterior fractures through the sacrum were reduced with posterior incisions and fixed with two Harrington threaded sacral rods (Figure sb).
radiograph showing pelvic disruption associated with acetabular ‘fractures’ - type 0. b, Postoperative radiograph showing internal fixation of the pelvic and acetabular fractures through simultaneous Kocher-Langenbeck and ilio-inguinal
incisions.
34
injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
1
Figure 8. a, Preoperative radiograph showing dislocation of the sacro-iliac joint, diastasis of the pubic symphysis and contralateral pubic fractures. There was a concomitant posterior fracture-dislocation of the ipsilateral hip. b, Postoperative radiograph showing rctropcritoneal plating of the sacro-iliac joint and anterior plating of the pubic symphysis and contralateral pubic ramus fracture. The hip was also reduced.
rami
Figure9. a, Postoperative radiograph of a patient with a Malgaigne fracture and bilateral femoral fractures. The pelvic fracture was stabilized with sacral bars posteriorly and external fixator of a Skis frame anteriorly. The femoral fractures were fixed with intramedullary nails during the same operative session. b, Postoperative radiograph showing fracture of the sacral ala and bilateral pubic rami fracture fixed with sacral bars and external fixator (which was removed). Note the residual internal rotation deformity of the involved hemipelvis in both patients.
I ________I_
Figure 10. Measurement view of the pelvis.
of posterior
displacement
of an inlet
Figure 11. Measurement outlet view of the pelvis.
of the vertical
displacement
on an
Leung et al.: Operative treatment of unstable pelvic fractures
Postoperative management The patients were allowed to sit out of bed as soon as possible. Non-weight-bearing walking was started as soon as the physical condition of the patient allowed. Graduated weight-bearing walking was started 6-8 weeks later, when the anterior external fixator was also removed if one was used. Full weight-bearing walking was started in 10-12 weeks. Assessment The functional outcome and the incidence of back pain, gait and limb length discrepancy were assessed. Radiological assessment was with plain radiographs. A review of the literature provided no suggestions as to a suitable method for quantifying the displacement. The following method was adopted in our assessment: the inlet view shows the posterior displacement (Figure 10). A vertical line was drawn along the midline of the lumbar spines. Horizontal lines were drawn perpendicular to this central line tangential to the posterior crests and the distance between these two lines was noted. The outlet view shows the vertical displacement (Figure II). Similar measurements were used to assess the vertical displacement. The displacement was judged to be none, slight ( < 1 cm) or severe ( > I cm). For the rotational deformity, both the inlet and the anteroposterior views had to be used to judge the asymmetry of the hemipelvis. Quantification in this situation was difficult and not accurate. Therefore only the direction of the rotational displacement was noted.
Results The time between admission and operation ranged from 4 h to 5 days with an average of 2.5 days. The operative procedures are summarized in Tiblell. A total of 15 posterior fracture-dislocations were fixed with parallel Harriligton sacral rods; 10 were fixed with two two-hole 4.5 Dynamic compression plates; one was fixed with two cancellous screws transfixing the sacro-iliac joints from the posterior ilium. Half of the anterior fractures were fixed with external fixators in the configuration of a S&is frame. The other half were fixed internally with plates. The operative time for fixing the pelvic fractures ranged from 2 to 4.5 h with an average of 3.2 h. Postoperatively, the duration of immobilization ranged from 3 to 14 days with an average of 7 days. The duration of non-weight-bearing walking ranged from 3 to 6 weeks with an average of 4.8 weeks. The duration of full weight-bearing walking ranged from 8 to 14 weeks with an average of 11.5 weeks. The duration of hospital stay ranged from 4 to 16 weeks with an average of 9.8 weeks. The average period of sick leave required was 6.5 months. The early morbidities are shown in TableIll. Six patients with an external fixator for the anterior fractures had minor pin tract discharge; two of them had a positive bacteriological culture. All except one subsided with simple local treatment. The patient in whom the local treatment failed was doubly incontinent and had a urinary tract infection. The infection subsequently spread to the hip joint which eventually fused. One patient had the external fixator dislodged at the end of the 4th week after the operation. He was confined to bed tor 2 more weeks before further ambulation. Two patients with sacral rod fixation of the posterior fractures developed superficial wound infection which subsided after non-operative treatment.
35
Late sequelae The patients were assessed with a minimum follow-up period of 12 months. The follow-up period ranged from 12 to 46 months, with an average of 19 months. The late results are shown in Table IV. Twenty (71.4 per cent) patients claimed to have no discomfort. Back pain. Five (17.8 per cent) of patients had moderate back pain that required occasional analgesics. All of these patients had sacral bar fixation for posterior fracturedislocations. As for the anterior fixation method, three of them were fixed with the external fixators and the rest were fixed with plates. Radiologically, two of these patients had residual internal rotation; one had internal rotation and vertical displacement of less than 1 cm. The rest had no demonstrable pelvic deformity on radiographic measurements. Neurological deficit. Of the three patients with neurological complications, one had partial sensory recovery. The other two showed neither deterioration nor recovery. One patient with double incontinence had return of bowel control. Two patients complained of prominence of the ends of the sacral rods in the posterior wound. Four patients walked with a limp. Two of these patients had back pain with pelvic asymmetry and leg length discrepancy of 15 mm. The patient with hip fusion due to infection had a 25 mm leg length discrepancy. One female patient delivered a baby by Caesarean section 3 years after the operation on the pelvis. A total of 20 (71.4 per cent) patients returned to work. Of these, 13 returned to their previous jobs and seven changed
Table IL List of operative procedures performed Procedure
No. of patients
Anterior Plating External fixator
14 14
Posterior Sacral rods Two-hole DCP Screws
15 10 1
Table III. List- of early complications Complication Pin tract discharge Pin tract infection Dislodged external fixator Superficial wound infection
No. of patients 2 2 1 2
Table IV. Incidence of late sequelae No complaints Back pain Neurological deficit Prominence of ends of the sacral rods Limping gait Leg length discrepancy 25mm
20 &2) 2 2 2 2
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Injury: the British Journal of Accident Surgery (1992) Vol. 23/No.
to more sedentary
work. Three patients did not resume working because of residual back pain and injuries to other systems. The remaining five patients did not work for reasons unconnected with the pelvic injury. Radiologically, there was no non-union of the fractures. The position of the reduced sacro-iliac joints remained unchanged compared with the immediate postoperative films. There were seven patients with residual internal rotation of the hemipelvis. Of these seven patients, three had less than I cm residual vertical displacement of the hemipelvis but no posterior displacement. All of these patients had sacral bar fixation of the posterior elements (Figures 9a,b). Six of them had external fixators for the anterior fractures and one had plating for the anterior fracture. Patients with retroperitoneal plating of the sacroiliac joints had minimal residual deformity of the hemipelvis.
1
fixation into the first sacral body may be an alternative to extensive bilateral retroperitoneal exposure for plating (Matta and Saucedo, 1989). Harrington sacral bar fixation is one method of achieving quick fixation and good stability (Shaw et al., 1985) provided that the problem of internal rotation of the hemipelvis is taken into consideration. For the anterior fractures, open reduction and plating was also better accepted by the patient and the complications were minimal (Figures 5b, Sb). However, in bilateral pubic fractures or multiple injuries (Fi’res 9a, gb), anterior external fixation might be preferred to achieve anterior stability with minimal surgical trauma. In these cases, intraoperative radiographic screening should be employed to check internal rotational deformity of the hemipelvis due to excessive compression.
Conclusion Discussion Unstable pelvic fractures are serious injuries with important mortality and morbidity (Hesp et al., 1985; Moreno et al., 1986). Non-operative treatment was most popular, but was associated with the disadvantages of prolonged traction in bed, difficult nursing and discomfort. Moreover, late complications included a high incidence of back pain, limping and leg length discrepancy due to malunion (Raf, 1966; Slitis and Huittinen, 1972; Semba et al., 1983; Henderson, 1989). With the modem concept of treating fractures and multiplyinjured patients, attention is drawn to the early operative stabilization of unstable pelvic fractures (Hesp et al., 1985; Goldstein et al., 1986). In this study, there was no operative mortality. Average duration of the operation was 3.2 h. Our patients could be mobilized much earlier despite the multiple injuries. As a result, the duration of hospital stay was much shortened. Complications were minimal, and consisted mainly of minor pin tract discharges and superficial infections of the posterior wounds in patients who had anterior external fixation combined with posterior sacral bar fixation. The case of septic arthritis of the hip probably resulted from bacteraemia arising from urinary tract infection. Functional recovery was excellent. There was minimal leg length discrepancy and gait disturbance. A total of 20 patients (71.4 per cent) resumed work. One patient delivered a baby by Caesarean section 3 years after the injury. The late results were also encouraging. Five patients (17.8 per cent) had residual back pain and required occasional analgesics. This is considerably lower than that reported for non-operative treatment (Raf, 1966; Slatis and Huittinen, 1972; Semba et al., 1983; Henderson, 1989). For the choice of operative treatment, it has been shown in this study that most of the complications were from the external fixator and the sacral bar fixation. In fact, five of the seven patients who had external fixation combined with posterior sacral bar fixation had residual internal rotational deformity and residual back pain. The reasons for these were the excessive compression by the external fixator and the difficulties associated with reduction of the sacro-iliac complex from a posterior approach. There were no complications from plating the sacro-iliac joints and the anterior fractures. The retroperitoneal approach provided direct exposure of the sacro-iliac joint and hence allowed accurate reduction and effective fusion by plating (Simpson et al., 1987). However, decompression of the retroperitoneal haematoma may risk disturbing the tamponade effect and is therefore not recommended within the first 48 h. In bilateral sacro-iliac fractures or dislocations, posterior transiliac screw
Unstable pelvic fractures are results of high-energy injury. Their frequent association with injuries in other systems makes early stabilization preferable in treating these multiply-injured patients. Our analysis of 28 patients treated with operative stabilization for unstable pelvic fractures shows that the operation is safe. Both early and late results are better than those treated by non-operative means.
References Bucholz R. W. (1981)The pathological
anatomy of Malgaigne fracture-dislocations of the pelvis. 1. Bone joint .%rg 63A, 400. Goldstein A., Phillips T., Sclafani S. J. A. et al. (1986) Early open reduction and internal fixation of the disrupted pelvic ring. 1. Trama 26, 325. Henderson R. C. (1989) The long-term results of nonoperatively treated major pelvic disruptions. I. O&up. Trauma 3, 41. Hesp W. L. E. M., Van der Werken C., Keunen R. W. M. et al. (1985) Unstable fractures and dislocations of the pelvic ring results of treatment in relation to the severity of injury. Nefh. J Surg. 37, 148. Holdsworth F. W. (1948) Dislocation and fracture-dislocation of the pelvis. 1. Bone joint Surg. 30B, 461. Huittinen V. M. and Slatis P. (1972) Nerve injury in double vertical pelvic fractures. Acfa. Chir. Scud. 138, 571. Kellam J. F., McMurtry R. Y., Paley D. et al. (1987) The unstable pelvic fracture-operative treatment. Orfhop. Clin. North Am. 18, 25. Looser K. C. and Crombie H. D. (1976) Pelvis fractures: an anatomic guide to severity of injury. Review of 100 cases. Am. J Surg. 132,638. Matta J. M. and Saucedo T. (1989) Internal fixation of pelvic ring fractures. Clin. Orfhop. Rel. Res. 242, 83. Monahan P. R. W. and Taylor R. G. (1975) Dislocation and fracture-dislocation of the pelvis. Injury 6, 325. Moreno C., Moore E. E., Rosenberger A. et al. (1986) Hemorrhage associated with major pelvic fracture: a multispecialty challenge. 1. Traum 26, 987. Naam N. H., Brown W. H., Hurd R. et al. (1983) Major pelvic fractures. Arch. Swg. 118,610. Raf L. (1966) Double vertical fractures of the pelvis. Acfa Chir. Scud. 131,298. Semba R. T., Yasukawa K. and Gustilo R. B. (1983) Critical analysis of results of 53 Malgaigne fractures of the pelvis. 1, Trauma 23, 535.
Leung et al.: Operative treatment of unstable pelvic frachues
Shaw J. A., Mino D. E., Werner F. W. et al. (1985) Posterior stabilisation of pelvic fractures by use of the threaded compression rods - case reports and mechanical testing. Clin. Orthop. Rel. Res. 192, 240. Simpson L. A., Waddell J. P., Leighton R. K. et al. (1987) Anterior approach and stabilization of the disrupted sacroiliac joint. J. Trauma 27, 1332. Slatis P. and Huittinen V. M. (1972) Double vertical fractures of the pelvis. Acfa Chir. Scand. 138, 799. Tile M. (ed.) (1984) Fracfures of the Pelvis and Acefabulum. Baltimore, etc: Williams & Wilkins.
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Tile M. (1988) Pelvic ring fractures: should they be fixed? J. Bone J&f Surg. 70B, I. Tile M., Lifeso R., Dickinson D. et al. (1982) Disruptions of the pelvic ring. Orfhop. Trans. 6, 324. Paper accepted
28 March
1991.
Requests for reprinfs shouM be addressed to: Dr K. 5. Leung, Senior Lecturer, Department of Orthopaedics and Traumatology, Prince of Wales Hospital, Shatin, N.T., Hong Kong.
