Crescent fractures of the pelvis treated by open reduction and internal fixation: a critique of Day’s guidelines

Comparison of the AO/OTA 1996/2007 and 2018 pelvic ring fracture classifications

Pelvic ring fractures may present with relevant mechanical and haemodynamic instability. Classifications of the bony or ligamentous injuries of the pelvic ring are well established. The most common classifications used analyse the injury mechanisms and the resulting instability of the pelvic ring structure. Fracture classifications should be simple and easy to use, comprehensive, and radiographically and anatomically based, resulting in a hierarchical alphanumeric order of types and subtypes and thereby allow adequate treatment decisions based on a high degree of inter- and intraobserver reliability. In 2018 a new AO/OTA pelvic ring fracture and dislocation classification was published that combined the most commonly used "historical" classification schemes, e.g. the Tile/AO classification and the classification according to Young and Burgess. Compared with these older classifications, several relevant changes were integrated in the 2018 edition. The changes between the AO/OTA 1996/2007 and 2018 classifications were analysed in detail. Overall, several problems were identified regarding the type-B pelvic ring injury classification. These changes may result in difficulties in classifying pelvic ring injuries and thereby prevent relevant comparisons between former and future clinical studies on pelvic injuries.Level of Evidence: V.

Insertion sites of iliosacral screws on the posterior ilium: Implications for posterior pelvic fixation

OBJECTIVES

Lateral compression type II pelvic ring injuries can be treated with fixation through open or percutaneous approaches depending on the injury pattern and available osseous fixation pathways. The start site of iliosacral screws to stabilize these injuries should be on the unstable posterior iliac fragment; however, our understanding of start sites for iliosacral screws has not been developed. The purpose of this study is to provide an analysis of iliosacral screw start sites on the posterior ilium to help guide treatment of pelvic ring injuries.

METHODS

One-hundred and seventeen consecutive patients at an academic level I trauma center with pelvic ring injuries who underwent surgical treatment with iliosacral screws were included in the final analysis. The start sites of iliosacral screws with confirmed intraosseous placement on a postoperative computed tomography were mapped on the posterior ilium and analyzed according to the sacral segment and type of iliosacral screw.

RESULTS

One-hundred and seventeen patients were included in the final analysis. Of the total of 272 iliosacral screw insertion sites analyzed, 145 (53%) were sacroiliac-style screws and 127 (47%) were transsacral screws. The insertion sites for sacroiliac-style screws and transsacral screws at different sacral segment levels can vary but have predictable regions on the posterior ilium relative to reliable osseous landmarks.

CONCLUSIONS

Iliosacral screws start sites on the posterior ilium have reliable regions that can be used to plan posterior fixation of pelvic ring injuries.

Open reduction and internal fixation of crescent fracture-dislocation: anterior or posterior approach?

INTRODUCTION

To date, the approach that prevails in the open reduction and internal fixation of crescent fracture-dislocations (CFD) remains unknown. This study aimed to compare the outcomes of CFD treated via the anterior or posterior approach.

MATERIALS AND METHODS

Data from 64 cases of CFDs openly reduced through an anterior (group A, n = 31) or a posterior (group B, n = 33) approach were retrospectively analyzed. Functional results, reduction quality, residual displacements in the axial and coronal planes, pelvic asymmetry deformity, and correlations between Day's classification were compared. Complications and fracture union were also recorded. All patients were followed up for at least 12 months.

RESULTS

The functional scores were similar between the two groups, and all fractures achieved good or excellent reduction postoperatively. In the coronal plane, the excellent/good ratio in group B was higher than in group A. The mean residual displacement in the coronal plane was significantly higher in group A than in group B, with group A showing greater displacement in both planes for Day I fractures and in the coronal plane for Day II fractures. The residual displacement in both planes for Day III fractures was comparable between the groups. The pelvic asymmetry deformity was equal between the two groups and among the different Day's fracture types.

CONCLUSIONS

Open reduction and internal fixation of CFDs obtained satisfactory outcomes through an anterior or posterior approach. The posterior approach achieved a better sacroiliac joint reduction. The optimal indication for the posterior approach was a Day I fracture, followed by a Day II fracture. No correlation was found between the surgical approach and reduction quality in Day III fractures.

Inaccuracies in the Use of the Majeed Pelvic Outcome Score: A Systematic Literature Review

OBJECTIVES

To evaluate the accuracy with which the Majeed Pelvic Score has been reported in the English literature.

DATA SOURCES

Databases used to search for literature were PubMed, Embase, and Ovid, restricted to English language from inception to October 2, 2018.

STUDY SELECTION

Search words used were: Majeed, pelvis, and outcome.

DATA EXTRACTION

Articles were assessed for descriptions of scoring and proper reporting of Majeed Pelvic Outcome Score.

DATA SYNTHESIS

Descriptive statistics were used to report the outcome of our findings.

CONCLUSIONS

Ninty-two English articles were identified. Twenty-four (26%) articles were identified as including methodology related to the use and scoring of the Majeed Pelvic score. The remaining 68 presented mean Majeed scores with no methodological information. None (0/92) discussed how the range of possible scores for the most severe function was applied. Six (7%) reported adjusted scores for patients not working. Three (3%) included a discussion of the scores as adjusted for patients working before injury compared with those not working. Ten (11%) addressed the categorization of scores by excellent to poor describing what raw scores defined those categories. We observed poor accuracy and notable inconsistency in the use and reporting of the Majeed Pelvic Outcome Score in the literature. These data demonstrate that interpretation and comparison of research reporting this score should be done cautiously. Future studies should include specific information as to how the Majeed instrument calculated to allow for verification of the presented scores and subsequent conclusions.

Fixation of Crescent Pelvic Fracture in a Tertiary Care Hospital: A Steep Learning Curve

Background

Crescent fracture-dislocation of sacroiliac joint is a type of lateral compression pelvic injury associated with instability. These fractures comprise 12% of lateral compression fractures.

Objective

The objective of this study is to share the experience and to assess the functional outcome of fixation in crescent fracture-dislocation.

Methods

We analyzed a descriptive case series with clinical data of 15 patients at the Department of Orthopedics Surgery at the Dr. Ruth K.M. Pfau Civil Hospital at Dow University of Health Sciences in Karachi, Pakistan, from January 2016 to August 2018. The patients were treated by closed and open fracture reduction and fixed with percutaneous screws and reconstruction plates.

Results

A total of 15 patients were included in this study with age ranging from 20 to 60 years (11 men [73%]; four women [27%]). According to the mechanism of injury, five (33%) had motorcycle accidents; four (27%) had collision while sitting in a car; three (20%) were pedestrians hit by a vehicle; four (27%) were injured while sitting in van; two (13%) had bus-related injury, and one (6.5%) presented with a history of wall collapse.

Five (33%) patients had type I fractures, seven (47%) had type II fractures, and three (20%) had type III fractures Associated injuries were midshaft femur fracture in two patients, contralateral superior and inferior rami fracture in three patients, and open tibia fracture in one patient. All fractures were fixed with reconstruction plates and screws. Patients were kept as non-weight-bearing on the injured joint for three weeks, mobilized non-weight-bearing on the contralateral leg after three weeks, and partial weight-bearing was started at eight weeks; full weight-bearing was started after three months. Nine patients (60%) had excellent outcomes, three (20%) had a good outcome, and three (20%) had a poor outcome.

Conclusion

Crescent fracture-dislocations are unstable injuries. These fractures should have proper reduction and fixation that will reduce pain, malunion, and shortening.