Operative stabilization of fracture dislocations of the sacroiliac joint

Posterior fracture dislocations of the sacroiliac joint (crescent fracture) represent a subset of lateral compression pelvic fractures. The crescent fracture consists of a posterior iliac wing fracture with extension into the sacroiliac joint and a dislocation of the inferior 1/2 of the sacroiliac joint. The posterior superior iliac spine remains firmly attached to the sacrum by the strong posterior ligaments. As a result of this combination of bony and soft tissue injury, the hemipelvis is rotationally unstable, but because the sacrospinous and sacrotuberous ligaments remain intact the involved hemipelvis is stable to vertically applied forces. Operative stabilization is necessary to restore articular congruity of the sacroiliac joint, pelvic stability, and to allow early mobilization of the patient. Stabilization of the pelvis may be achieved through either an anterior or a posterior approach with or without transarticular fixation. A posterolateral approach to the crescent fracture and a method of stabilization using extraarticular fixation, intertable lag screws and outer table antiglide plates are described. The results of using this technique in 22 patients are reviewed.

Thromboembolic complications in patients with pelvic trauma

Patients with pelvic trauma are known to be at increased risk for the development of thromboembolic complications. The incidence of deep venous thrombosis in patients with pelvic fractures is 35% to 60%. Proximal deep venous thrombosis, which is most likely to result in pulmonary embolism, occurs in 25% to 35% of these patients, and almost 1/2 of all proximal thrombi will be in the pelvic veins. The incidence of symptomatic pulmonary embolism in the pelvic trauma population is 2% to 10% whereas a greater proportion of patients will have clinically silent pulmonary embolism. Fatal pulmonary embolism occurs in 0.5% to 2% of patients with pelvic trauma. The cornerstone of effective management is prophylaxis and the most commonly used forms include low dose heparin, low molecular weight heparin, mechanical devices, and in some studies, inferior vena caval filters. Based on a critical review of the literature, in algorithm is proposed for the management of thromboprophylaxis in this trauma subgroup. This includes prophylaxis, screening, and treatment when proximal thrombosis is identified. Such a systematic approach to this potentially catastrophic problem may decrease the morbidity and mortality associated with thromboembolic complications in these patients.

The crescent fracture: a posterior fracture dislocation of the sacroiliac joint

Between October 1987 and August 1992, 22 patients with crescent fractures, a posterior fracture-dislocation of the sacroiliac joint, were admitted, treated, and available for review at Tampa General Hospital and The Hospital for Special Surgery. The purpose of the study was twofold: (a) to evaluate the incidence, severity, and pattern of associated injuries, and (b) to determine the efficacy of a treatment protocol using a posterior extrapelvic approach and extraarticular internal fixation. The study population was composed of 13 females and nine males; the average age was 25 years (range 10-52). Despite the fracture pattern resulting in a rotationally unstable hemipelvis, all patients were hemodynamically stable at the time of presentation. Fourteen patients (64%) had other associated injuries, including five (23%) with closed head injury. In all cases a posterior extrapelvic approach was used with an anatomic reduction of the fractured iliac wing and the sacroiliac joint dislocation. Stable extraarticular internal fixation was obtained using intertable lag screws and outer-table neutralization plates. All the fractures were clinically and radiographically healed within 8-10 weeks postoperatively, and there were no acute wound, neurologic, or vascular complications. One patient developed osteomyelitis of the iliac crest 6 months postoperatively.

Magnetic resonance venography to evaluate the deep venous system of the pelvis in patients who have an acetabular fracture

We performed a prospective, blinded study to assess and compare the values of preoperative contrast venography and magnetic resonance venography in the detection of deep venous thrombosis in the thigh and pelvis of forty-five consecutive patients who had a displaced acetabular fracture. The magnetic resonance venography and contrast venography were performed an average of seven days (range, one to twenty-nine days) after the injury. Twenty-four asymptomatic thrombi were identified with magnetic resonance venography in fifteen (33 percent) of the patients. Four of the thrombi were in the superficial femoral vein, nine were in the common femoral vein, one was in the external iliac vein, seven were in the internal iliac vein, and three were in the common iliac vein. Ten (42 percent) of the twenty-four thrombi were confirmed with contrast venography; nine of them were located in the thigh. The remaining fourteen thrombi (58 percent) that had been noted on magnetic resonance venography could not be seen with contrast venography because they were located either in the deep pelvic veins or in the uninjured extremity. The thrombi in the internal iliac vein were identified only with magnetic resonance venography. Twelve of the fifteen patients who had thrombi had a filter placed in the inferior vena cava preoperatively. In eight of these patients, the filter was placed because of the findings of magnetic resonance venography alone. Magnetic resonance venography resulted in a change in the therapeutic management of ten (22 per cent) of the forty-five patients. There were no pulmonary emboli. We concluded that magnetic resonance venography is superior to contrast venography for the preoperative evaluation of proximal deep venous thrombosis in patients who have an acetabular fracture. Magnetic resonance venography is non-invasive, does not require the use of contrast medium, images the proximal aspects of both lower extremities simultaneously, and, most importantly, allows for the identification of deep venous thrombosis in the pelvis.

Magnetic resonance imaging of the pelvis. New orthopaedic applications

A preliminary study of using magnetic resonance angiography to detect occult proximal thrombi in patients who had hip arthroplasty was done. Despite the presence of susceptibility artifact caused by metallic components, diagnostic visualization of thigh vessels was made in a preliminary series of 15 patients. Confirmation of all previously documented (by contrast venogram via dorsal foot vein cannulation or Doppler study) proximal thrombi was made in all 15 patients. One patient had a thrombus in the contralateral extremity that had been undetected by Doppler study; 4 additional pelvic thrombi occurred in 3 patients, which had been undocumented previously. Because magnetic resonance angiography is noninvasive, requiring no contrast agent, it has advantages over conventional venography to detect occult proximal thrombi. New fast spin echo sequences are discussed that enhance visualization of regional anatomic structures adjacent to metallic prosthetic components. Emphasis was placed on assessing the posterior soft tissue envelope in patients having recurrent dislocations after total hip arthroplasty, despite acceptable component alignment. Preliminary results show a consistent absence of a posterior pseudocapsule in patients having dislocations, as compared with control patients having no dislocations.

Computerized tomography for the evaluation of posttraumatic multiplane deformities of the tibia

Traditional assessment of posttraumatic multiplane deformities of the tibia includes radiographic evaluation with anteroposterior, lateral, and oblique radiographs for assessment of the coronal and sagittal deformities, and scanograms, teleroentgenograms, or orthoroentgenograms for the determination of limb length. Standard clinical measurements are used for the determination of rotational deformity. We report our technique and experience using a selected computerized tomography examination that provides accurate information necessary for the exact determination of the tibial deformity, and the preoperative planning of its correction. The technique is accurate, cost-effective, and safe, with less radiation exposure to the patient.

Intraoperative somatosensory evoked potential monitoring during acute pelvic fracture surgery

Independent clinical neurological evaluation and intraoperative somatosensory evoked potential (SSEP) monitoring was performed on 30 vertically unstable hemipelvis fractures in 28 patients undergoing acute open reduction and internal fixation. Preoperative ipsilateral neurologic injury of the sciatic/lumbosacral plexus was noted in 15 of 30 fractures (50%). Significant unilateral SSEP changes occurred during manipulative reduction of two displaced sacroiliac joints and one sacral fracture. Because of the expeditious response of the surgical team, with release of traction/retraction, SSEP returned to baseline and no patient sustained an iatrogenic nerve injury or worsening of their preoperatie neurologic status. The incidence of postinjury lumbosacral plexopathy in unstable pelvic fractures is high (50%) when careful preoperative evaluation including SSEP is performed. The use of intraoperative SSEP monitoring is feasible in acute posterior pelvic fracture surgery and can help identify potential intraoperative iatrogenic lumbosacral neurological compromise.

MR imaging of acetabular fractures: value in detecting femoral head injury, intraarticular fragments, and sciatic nerve injury

OBJECTIVE

The purpose of this prospective study was to compare the value of MR imaging in the detection of injuries associated with acute acetabular fractures (femoral head fracture, free fragments within the hip joint, and injury to the sciatic nerve) with the value of preoperative CT examinations, intraoperative inspection, intraoperative somatosensory evoked potentials (SEP), and clinical neurologic examinations.

SUBJECTS AND METHODS

Coronal fat suppressed long TR/TE and unenhanced and contrast-enhanced T1-weighted MR images were obtained preoperatively in 37 patients with acetabular fractures. The sciatic nerve was assessed for injury and the femoral head was assessed for fracture, dislocation, and contusion. MR results were compared with CT findings for acetabular fractures and fractures of the femoral head. The appearance of the sciatic nerve on MR images was correlated with intraoperative changes in SEP and results of the clinical neurologic examination.

RESULTS

Although MR images showed acetabular fractures, intraarticular fragments were often obscured. Fragments were readily apparent on CT scans. MR images showed fracture of the femoral head in 10 (27%) of 37 cases. Nine of these fractures also were seen on CT scans. MR images showed subchondral contusion of the femoral head in 24 (65%) of 37 cases. The same areas appeared normal on CT scans. MR images of the sciatic nerve obtained after injection of contrast material showed intraneural or perineural enhancement in all patients with either changes in baseline SEP (n = 19) or preoperative neurologic deficit (n = 10). Although baseline changes in SEP were more common with intraneural enhancement, the difference in the prevalence of neurologic deficits was not significant. The preoperative enhancement pattern alone could not be used to predict a neurologic deficit.

CONCLUSIONS

MR imaging of acetabular fractures can be used to detect subclinical injury of the sciatic nerve and occult injuries of the femoral head not readily apparent on CT scans. However, intraarticular fragments may be obscured.

Management of complex acetabular fractures through single nonextensile exposures

A review of 127 surgically treated acetabular fractures, treated between August 1986 and January 1991, using single nonextensile surgical exposures and indirect reduction techniques was conducted. There were 31 elementary and 96 associated fractures (Letournel). In 34 cases the fracture involved only one column and in nine cases an extensile or combined exposure was required, therefore these cases were excluded from the study. This left 84 complex fractures (involving two column) for review. In all cases either the anterior (ilioinguinal) or posterior (Kocher-Langenbeck) exposure was used. Indirect reduction of the involved and opposite column was achieved with either the Judet table, lateral trochanteric traction, or the femoral distractor. A satisfactory reduction was obtained in 90.5% (76 of 84) of the cases (concentric, gap < 3 mm, step off < 2 mm). The incidence of acute infection and heterotopic ossification was 0% and 2%, respectively.

Somatosensory evoked potential monitoring in the surgical treatment of acute, displaced acetabular fractures. Results of a prospective study

A prospective protocol was developed to prevent iatrogenic nerve injury during the surgical treatment of acute, displaced acetabular fractures in 103 patients. The protocol included an independent neurologic evaluation and perioperative somatosensory evoked potential (SEP) monitoring (tibial division only). The incidence of posttraumatic nerve injury was 29% (30/103 patients). The incidence of postoperative nerve injury was 5% (5/103 patients): complete sciatic, 0; tibial division, 0; peroneal division, 5. Somatosensory evoked potential monitoring of the tibial division is effective in preventing injury to this division. If perioperative SEP monitoring is used, independent stimulation of the tibial and peroneal divisions is recommended. High-risk groups for perioperative injury to the sciatic nerve include those patients with significant posterior column or wall displacement or posttraumatic sciatic nerve injury.

The treatment of open and/or unstable tibial fractures with an unreamed double-locked tibial nail

A multicenter, prospective study was conducted to assess the efficacy of an unreamed, double-locked tibial nail for the acute management of open and/or unstable tibial fractures. Seventy-seven acute unstable and/or open tibial fractures in 74 patients were treated from December 1986 to February 1989. Forty fractures were closed and 37 were open; 25% occurred in polytraumatized patients and 39% of the patients had additional fractures. All closed tibial fractures healed at an average of 14.2 weeks; 94.6% of the open tibial fractures healed at an average of 20.1 weeks. There were no infections in the closed tibial fracture group. There were 4 infections among the 37 patients (11%) in the open tibial fracture group, 2 superficial and 2 deep. There were 7 problems intraoperatively (8.4%) with fin deployment: 2 fins bent during nail insertion, 4 fins penetrated the cortex, while 1 set of fins only partially deployed. Difficulty was encountered with proximal screw insertion in one third of the cases. Considering the high energy of these injuries, the treatment of open and/or unstable tibial fractures with an unreamed, double-locked tibial nail can offer the surgeon a high rate of union (97%) with minimal complications. The low infection rate found in this series indicates that this nail may be of particular benefit in the treatment of closed and select open tibial fractures.

Intraarticular "pilon" fracture of the tibia

Classification and treatment options for the management of tibial pilon fractures are reviewed. For comminuted and/or displaced fractures that require open reduction and internal fixation, a detailed description of the surgical technique, including indirect reduction techniques, is provided. Thirty-four pilon fractures (32 patients) treated during a period of five years (1984-1989) were reviewed. All were high-energy injuries (15 patients with multiple trauma) with Rüedi-Allgöwer Type II in 26 and Type III in eight. Eighteen (56%) were open fractures. Six fractures were treated with external fixation and the remaining 28 with open reduction and internal fixation. The patient follow-up examination period averaged 16.2 months (range, six to 38 months). Thirty (88%) fractures had united by 16 weeks (two delayed unions, one below knee amputation, and one plate breakage). In the 26 Type II fractures, functional grading found 17 excellent (65%) and six (23%) poor results. In the eight Type III fractures, there were four (50%) excellent and three (37%) poor results. Complications included one superficial pin-tract infection and two deep wound infections, both in Grade II open fractures.

Retrograde reamed femoral nailing

Closed, reamed, antegrade nailing remains the standard of care for femoral shaft fractures. This technique however, may be less attractive in the management of femoral shaft fractures associated with (a) ipsilateral acetabular, pelvis, or femoral neck fractures; (b) polytrauma requiring multiple simultaneous surgical procedures; and (c) pregnancy. We now report on our experience with the retrograde femoral nailing as a treatment option in these situations. Between 4/88 and 10/90, 29 retrograde femoral nailing in 24 patients were attempted. Average age was 29.3 (16-74) years. Five fractures were open. Fracture location was isthmal in 14 and infraisthmal in 15. The comminution was classified according to Winquist and Hansen: I(10), II(7), III(7), and IV(5). Nailing was possible in 28/29 cases. Insertion was made through an extraarticular medial condylar portal. Nail diameter ranged from 10 to 13 mm. An AO Universal Femoral Nail was used in the first 11 cases; all subsequent fractures were stabilized using an AO Universal Tibial Nail because its design appeared better suited to this technique. Follow-up was possible for 25 fractures in 21 patients and averaged 16.0 (range, 11-27); months 23/25 (92%) fractures healed within 12 weeks. No case was associated with an infection, loss of reduction, or nail failure. Knee flexion averaged 122 degrees; only two knees had an extensor lag of > 5 degrees. Intraoperative complications included three cases of crack propagation at the insertion site, and four infraisthmal malreductions (two valgus, two flexion). Based on these results, we feel that retrograde reamed femoral nailing is a suitable alternative to antegrade nailing and should be considered in situations where proximal access is neither possible nor desirable.

Modified-tension band wiring of displaced surgical neck fractures of the humerus

Fifteen two-part surgical neck fractures of the humerus in 14 patients were treated with a modified-tension band wiring technique. In this technique, one wire is placed through the greater tuberosity and supraspinatus tendon, and the other wire is placed through the lesser tuberosity and subscapularis tendon. Each wire is connected to the shaft in a similar figure-of-eight technique. This places the wires approximately 90° apart from each other, with neither wire crossing over the biceps tendon. Four (26.7%) fractures had early loss of fixation, and one patient was lost to follow-up. Follow-up evaluation in the remaining 10 fractures (nine patients) averaged 33.4 months (range 26 to 53 months). Clinically, there were three (30%) excellent results, five (50%) satisfactory results, one (10%) unsatisfactory result, and one (10%) failure with the rating scale described by Neer. Based upon these results we cannot recommend the tension band wiring technique used. We consider the high incidence of loss of fixation (26.7%) reported in this series to be unacceptable.

Indirect reduction and tension-band plating of tibial non-union with deformity

Thirty-three patients who had a maligned non-union of the tibial diaphysis were treated by limited open exposure, indirect reduction with a femoral distractor, tension-band plating, lag-screw fixation, and autogenous bone-grafting. The time from the injury to treatment of the non-union averaged twenty-nine months. Twenty-two of the fractures were originally open and sixteen fractures had had a previous infection before treatment of the non-union. The non-unions were classified as hypertrophic in eight patients, oligotrophic in eighteen, and atrophic in seven. All had severe deformity, or the nature or level of the non-union, or both, precluded intramedullary nailing as a treatment option. All thirty-three non-unions healed at an average of four months; the average length of follow-up was nineteen months. The deformity was corrected, within acceptable limits, in thirty-two of the patients. Full motion of the knee was achieved in twenty-nine patients and of the ankle, in eighteen. Complications included four instances of superficial skin breakdowns, one deep infection, and one fracture of the plate. For non-unions of the tibial diaphysis with deformity that are not amenable to intramedullary nailing, the techniques of limited exposure, indirect reduction, tension-band plating, and bone-grafting can yield excellent anatomical and functional results.

Stabilization of acetabular fractures in elderly patients

Eighteen patients who were sixty years or older and had an acute displaced fracture of the acetabulum were managed with open reduction and internal fixation. The average age of the patients was sixty-seven years (range, sixty to eighty-one years). Nine fractures were a result of a motor-vehicle accident, and nine occurred in a fall. Nine patients had multiple associated injuries, and most (sixteen patients) had other complex acetabular fractures. All of the patients had open reduction and internal fixation with either the ilioinguinal approach (thirteen patients) or the Kocher-Langenbeck approach (five patients). All patients were managed postoperatively with early mobilization and physical therapy. All fractures united, and only one patient had a partial loss of reduction. Four patients who had a concentric reduction had a gap of as much as three millimeters in the articular surface due to comminution of the fracture. The complications included two pulmonary emboli, which resolved with anticoagulation, and one undetected intra-articular fragment, which led to an additional operation. No infections or iatrogenic nerve injuries were noted. Seventeen of the eighteen patients were followed for at least two years (average, thirty-one months). These patients had an average Harris hip-score of 90 points postoperatively. The treatment was regarded as having failed in only one patient. Open reduction and internal fixation of selected displaced acetabular fractures in the elderly can yield good results and may obviate the need for early and often difficult total hip arthroplasty.

Evaluation of acetabular fractures with two- and three-dimensional CT

The authors applied a widely used radiographic system of classifying acetabular fractures to axial computed tomographic (CT) scans and three-dimensional reconstructions in over 100 cases. In the classification system, fractures are analyzed according to the extent of involvement of two acetabular columns--the posterior and the anterior. To provide a better understanding of the CT anatomy of the acetabulum, the authors defined the boundaries of the columns on axial CT scans. They illustrated the most common fractures (posterior wall, transverse, transverse with posterior wall, and both columns) with radiographs, axial CT scans, and three-dimensional reconstructions. Axial CT scans readily demonstrated the fractures and presence of intraarticular fragments. Three-dimensional images helped in understanding the precise plane of the fracture, the degree of disruption of the articular surface, and spatial relationships of fragments. Although present three-dimensional CT is not without limitations, the authors believe that the technique is valuable and that, in their experience, it has facilitated preoperative planning.

Somatosensory evoked potential monitoring in the surgical management of acute acetabular fractures

Fifty patients undergoing acute acetabular fracture surgery had intraoperative somatosensory evoked potential (SSEP) monitoring. Group II, the final 38 patients, in addition had independent neurological evaluation preoperatively and postoperatively. Thirteen of 50 patients (26%) had preoperative sciatic nerve involvement. Fourteen of 50 patients (28%) developed significant intraoperative SSEP changes (decreased amplitude, increased latency). When the nerve was involved preoperatively (high-risk group), changes in SSEP occurred in 60% of patients. Iatrogenic sciatic/peroneal neuropraxia occurred in only one patient in the series (2%), and this resolved within 4 months. These results compare favorably to the incidence of 5-18% reported in the literature. We conclude SSEP is feasible and should be used in the operative treatment of acetabular fractures, especially the posterior fracture patterns and for those in the high-risk group.

Internal fixation of the distal humerus: a biomechanical comparison of methods

Three commonly used configurations of various implants used for fixation of distal humeral fractures were quantitatively compared. The double plate construct, irrespective of plate type (1/3 tubular and/or 3.5 mm reconstruction plate), was significantly stronger, both in rigidity and fatigue testing, than cross screws or the single "Y" plate. If rigid stabilization of supracondylar or bicondylar distal humeral fractures is desired, then two plate constructs, at right angles (the ulna plate medially, the lateral plate posteriorly), are biomechanically optimal.