Instability of the posterior pelvic ring associated with disruption of the pubic symphysis

Pelvic Ring Injuries: Stable or Not?

Pelvic ring injuries occur in varying severity and in vastly different patient demographics. Knowledge regarding which of these injuries require surgical intervention and which can be managed nonsurgically continues to evolve. Previous studies have shown validated criteria for sacral fractures and the posterior ring, explored the role of examination under anesthesia, and other forms of dynamic imaging. Although there is substantial information available, a comprehensive synthesis of this information is lacking. This article provides a comprehensive review of radiographic markers suggestive of stability, discusses treatment strategies, and proposes a treatment algorithm that is easily understood and applicable to not only those with a trauma background but also the general orthopaedic surgeon who will see these injuries frequently while on call.

Percutaneous Fixation for Traumatic Symphysis Pubis Disruption-Are the Results Superior Compared to Open Techniques? A Systematic Review and Meta-Analysis of Clinical and Biomechanical Outcomes

INTRODUCTION

Open reduction and reconstruction plate and screws fixation (RPSF) is considered the gold standard for the treatment of traumatic symphysis pubis diastasis (SPD). Percutaneous cannulated screw fixation (PCSF) has recently gained popularity as it may reduce operative time and morbidity. The current systematic review aims to compare the clinical and radiological outcomes of PCSF and RPSF in traumatic SPD and analyze the biomechanical effectiveness of PCSF.

MATERIAL AND METHODS

The Medline, Scopus, and Cochrane databases were searched until February 2023. The primary outcomes were the incidence of implant failure and revision surgery and the amount of displacement of symphysis pubis. Secondary outcomes were the intraoperative blood loss, the scar length, the operative time, the wound infection, and the patients' functional improvement.

RESULTS

Six clinical trial studies with a total of 184 patients and nine biomechanical studies were included. There was no significant difference between the two groups regarding the incidence of implant failure, the prevalence of revision surgery, and the amount of postoperative loss of reduction (p > 0.05 for all outcomes). The intraoperative blood loss (14.9 ± 4.2 mL for PCSF versus 162.7 ± 47.6 mL for PCSF, p < 0.001) and the incision length (1.7 ± 0.9 mL for PCSF versus 8 ± 1.4 mL for PCSF, p < 0.001) were significantly lower after PCSF. The mean operative time was 37 ± 19.1 min for PCSF and 68.9 ± 13.6 min for RPSF (p < 0.001). The infection rate was less frequent in the PCSF group (3% for PCSF versus 14.3% for RPSF, p = 0.01). One clinical trial reported better functional recovery after PCSF. In all biomechanical studies, the threshold for implant failure was beyond the applied forces corresponding to daily activities.

CONCLUSIONS

PCSF for traumatic SPD is associated with less operative time, less blood loss, and a lower infection rate when compared to conventional plate techniques without increasing the incidence of postoperative fixation failure and revision surgery. Moreover, PCSF has been proven to be biomechanically sufficient for stabilization. Therefore, it should be considered an efficient and viable alternative for the reconstruction of SPD when closed reduction can be adequately achieved.

Surgical stabilisation in equivocal pelvic ring injuries - Into the grey zone

Pelvic ring injuries comprise a spectrum of bony, ligamentous and muscular injuries, described by several common classification systems. However, the majority of injuries lie in areas of intermediate severity, where complexity and variable nature make it extremely hard to define in detail. This fact and associated injuries make it extremely difficult to conduct randomised control trials, with purpose to direct treatment guidelines. Thus, special interest and expertise are required by pelvic trauma surgeons, while surgical indications and fixation methods rely on their experience, at least in part. Namely, a significant grey zone of indication exists. As fixation methods evolve, specifically percutaneous fixation using osseous fixation pathways, some injuries in which morbidity bound with surgical fixation was considered too high relative to its benefits, may be considered eligible for surgical treatment nowadays. Moreover, due to significant progress in the treatment of the acute polytrauma casualties, the survival rate increased over the years, emphasizing the effect of long-term morbidity and functional outcome of pelvic ring injuries. The purpose of this manuscript is to describe the equivocal areas of controversies, hence "the grey zone", and to provide the readership with up-to-date published data. We aimed to collect and detail clinical and radiological clues in the diagnosis of intermediate unstable anterior-posterior compression and lateral compression injuries, and for the selection of treatment methods and sequence. Recent publications have provided some insights into specific injury features that are correlated with increased chance of instability, pain and delay in ambulation. Specific focus is given to the utility of examination under anaesthesia in selected cases. Other publications surveyed the shared experience of pelvic trauma surgeons as for the classification, indication and treatment sequence of pelvic ring injuries. Although the data hasn't matured yet to a comprehensive treatment algorithm, it may serve clinicians well when making treatment decisions in the grey zone of pelvic ring injuries, and serve as a basis for future prospective studies.

[Triangular minimally invasive spinopelvic stabilization for type C pelvic fractures according to AO/OTA and type IV according to FFP]

INTRODUCTION

Spinopelvic instability is common in type IV fragility fractures of the pelvic ring (FFP) and type C traumatic pelvic fractures. This results in the indications for operative stabilization using a spinopelvic support. Due to the variety of surgical techniques for spinopelvic support it is unclear what importance a minimally invasive spinopelvic screw-rod osteosynthesis can have.

MATERIAL AND METHODS

In the retrospective clinical study over a period of 2 years, 23 patients (median age 67 years, 5 male and 18 female) with unstable pelvic fractures (FFP type IV: n = 12, AO/OTA type C: n = 11) treated by triangular minimally invasive spinopelvic stabilization (TMSS) were included in the study. The patient data were examined with respect to the parameters gender, age, fracture morphology, intraoperative blood loss, operating time, postoperative infection, postoperative reduction result in the computed tomography (CT) imaging and screw loosening.

RESULTS

The average age of the 11 type C fractures was 43 years and that of the 12 FFP type IV fractures was 80 years. The follow-up period was on average 12.2 months. The average operation time was 67 min, the blood loss was 70 ml, there were 2 postoperative infections and 4 cases of screw loosening. The reduction according to Matta was < 4 mm for all FFP and between 4-20 mm for traumatic pelvic fractures. Symptomatic pseudarthroses occurred in 3 cases.

CONCLUSION

The triangular minimally invasive spinopelvic stabilization (TMSS) showed a stable and sufficient treatment of the type IV fragility fractures and in the slightly displaced type C traumatic pelvic fractures. Coarse fracture dislocations limit the procedure.

Orthotics to Improve Pain in a Patient With Multiple Internal Fixations and Multilevel Thoracic Fusion

The authors present the case of a 24-year-old man who sustained multiple injuries during a hard landing following a parachute jump. These injuries included a right sacral fracture, bilateral femoral fractures, a separated pubic symphysis, and compression fractures of the fifth and sixth thoracic vertebrae. He was treated with a right sacroiliac joint fixation, pubic symphysis fixation, open reduction internal fixation of his bilateral femurs, and fusion of the third through seventh thoracic vertebrae. The patient experienced back pain, bilateral hip pain, and bilateral knee pain resistant to chiropractic and medical treatments. The patient presented 2 years after his aforementioned surgical procedures for treatment of persistent postoperative pain at the Physical Medicine and Rehabilitation service at the Veterans Affairs Medical Center in Hampton, Virginia. His treatment involved gait correction achieved using a left-sided heel lift and a transition to custom molded orthotics that incorporated the lift. This treatment leveled his sacral base and resulted in a simultaneous decrease in his self-reported pain scores.

Sacroiliac screw versus a minimally invasive adjustable plate for Zone II sacral fractures: a retrospective study

OBJECTIVE

Fracture line of the sacrum always involves the Zone II region because sacral foramina are anatomically and physiologically weak regions of the sacrum. The purpose of this study is to compare the therapeutic effects of a sacroiliac screw and a minimally invasive adjustable plate (MIAP) for Zone II sacral fractures.

METHODS

Patients with unilateral Zone II sacral fractures fixed with a unilateral sacroiliac screw or MIAP from August 2009 to January 2016 were recruited into this study and were divided into two groups: group A (sacroiliac screw) and group B (MIAP). Surgical time, blood loss, frequency of intraoperative fluoroscopy, and relative complications were reviewed. Radiographs and CT scans were routinely acquired to evaluate the fracture displacement and reduction quality. Fracture healing was evaluated in the radiographs at each follow-up. Functional outcome was assessed based upon the Majeed scoring system at the final follow-up.

RESULTS

Thirty-one patients in group A and thirty-nine patients in group B were included in this study. No significant differences in average surgical time (P = 0.221) or blood loss (P = 0.234) were noted between group A and group B. The mean frequency of intraoperative fluoroscopy was 15.74±2.98 in group A and 6.08±1.94 in group B (P = 0.000). All fractures healed well within four months in all patients, and the healing time exhibited no significant difference between the two groups (P = 0.579). Satisfactory rates of reduction quality and functional outcome were not statistically different between the two groups (P > 0.05). The complication rate was 16.13% (5/31) in group A and 5.13% (2/39) in group B (P = 0.222).

CONCLUSION

MIAP has a fixation effect and exhibits reduction potential for Zone II sacral fractures. Favourable radiographic and functional results could be obtained through the MIAP technique, which is easy to conduct without pre-contouring. Compared with the unilateral S1 sacroiliac screw technique, repeated projections and iatrogenic sacral injury can be avoided.

Fixation Strategy Using Sequential Intraoperative Examination Under Anesthesia for Unstable Lateral Compression Pelvic Ring Injuries Reliably Predicts Union with Minimal Displacement

BACKGROUND

Examination under anesthesia (EUA) has been used to identify pelvic instability. Surgeons may utilize percutaneous methods for posterior and anterior pelvic ring stabilization. We developed an intraoperative strategy whereby posterior fixation is performed, with reassessment using sequential EUA to determine the need for anterior fixation. Our aim in the current study was to evaluate whether this strategy reliably results in union with minimal displacement.

METHODS

This was a multicenter retrospective study involving adult patients with closed lateral compression (LC) pelvic ring injuries treated during the period of 2013 to 2016. Included were patients who underwent percutaneous pelvic fixation based on sequential EUA. Data points included patient demographics, injury and fixation details, and displacement as observed on follow-up radiographs.

RESULTS

Complete documentation was available for 74 patients (mean age, 41 years). The mean duration of follow was 11 months. Fifty-three of the patients had LC-1 injuries, 19 had LC-2 injuries, and 2 had LC-3 injuries. Twenty-five (47.2%) of the 53 patients with LC-1 and 11 (57.9%) of the 19 patients with LC-2 injuries did not undergo anterior fixation on the basis of the algorithm. The 36 LC-1 or LC-2 patients who underwent combined anterior and posterior fixation had no measurable displacement at union. Of the 36 LC-1 or LC-2 patients with no anterior fixation, 27 with unilateral rami fractures had no measurable displacement at union. The remaining 9 LC-1 or LC-2 cases with no anterior fixation had bilateral superior and inferior rami fractures; each of these patients demonstrated displacement (mean, 7.5 mm; range, 5 to 12 mm) within 6 weeks of fixation that remained until union. All patients had protected weight-bearing for 12 weeks.

CONCLUSIONS

A fixation strategy based on sequential intraoperative EUA reliably results in union with minimal displacement for unstable LC pelvic ring injuries. Injuries requiring combined anterior and posterior fixation healed with no displacement. Those without anterior fixation and a unilateral ramus fracture healed with no displacement. In the presence of bilateral rami fractures, even with a negative finding on sequential EUA, the pelvis healed with 7.5 mm average displacement. Surgeons may consider anterior fixation to prevent this displacement.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Treatment of Unstable Posterior Pelvic Ring Fracture with Pedicle Screw-Rod Fixator Versus Locking Compression Plate: A Comparative Study

Background

The aim of this study was to assess the clinical results of treatment for unstable posterior pelvic fractures using a pedicle screw-rod fixator compared to use of a locking compression plate.

Material/Methods

A retrospective study was performed between June 2010 and May 2014 and the data were collected from 46 patients with unstable posterior pelvic ring fractures. All patients were treated using either a pedicle screw-rod fixator (study group, 24 patients) or locking compression plate (control group, 22 patients). In these patients, causes of injury included traffic accidents (n=27), fall from height (n=12), and crushing accidents (n=7). The quality of reduction and radiological grading were assessed. Clinical assessments included the operation time, times of X-ray exposures, bleeding volume during operation, incision length, and Majeed postoperative functional evaluation.

Results

No iatrogenic neurovascular injuries occurred during the operations in these 2 groups. The average follow-up time was 24.5 months. All fractures were healed. The significant differences (P<0.05) between the 2 groups were operation duration, size of incision, and intraoperative bleeding volume. Statistically significant differences in the Majeed postoperative functional evaluation and times of X-ray exposures were not found between the 2 groups.

Conclusions

Similar clinical effects were achieved in treating the posterior pelvic ring fractures using the pedicle screw-rod fixator and the locking compression plate. However, the pedicle screw-rod fixator has the advantages of smaller incision, shorter duration of the operation, and less bleeding volume compared to using the locking compression plate.

Underestimated Sacroiliac Joint Lesion on Computed Tomography in Pelvic Open-book Injury: A Case Report

The classification of anteroposterior compression (APC) injury type is based on using static radiographs, stress radiographs are known as a useful adjunct in classifying type of APC pelvic injuries. According to a recent article, the intraoperative stress examination has led to a change in the treatment plan in more than 25% of patients on 22 patients presumed APC type I (symphyseal diastasis <2.5 cm) injuries. Here authors present a case demonstrating a necessity of intraoperative stress test for excluding concealed posterior ring disruption.

Posterior Fixation of APC-2 Pelvic Ring Injuries Decreases Rates of Anterior Plate Failure and Malunion

BACKGROUND

Biomechanical studies suggest that augmenting anterior fixation of the pelvic ring with posterior fixation increases stability. Prior clinical studies have assessed radiographic outcomes following plate fixation of the symphysis. However, to our knowledge, none have directly compared the radiographic and clinical outcomes of anterior plate fixation alone with the outcomes of such plate fixation with the addition of posterior percutaneous screw fixation in the treatment of a partially disrupted hemipelvis. We attempted to determine whether use of an anterior symphyseal plate alone is adequate to control sagittal and coronal plane rotation and prevent malunion of an anteroposterior compression type-2 (APC-2) pelvic ring injury.

METHODS

The records of all skeletally mature patients with a traumatic pelvic disruption treated from 2004 to 2014 with an anterior symphyseal plate with or without a posterior iliosacral screw were retrospectively reviewed. Patients with an APC-2 pelvic ring injury evidenced by computed tomography (CT) were included in the study and divided into 2 groups: (1) fixation of the symphysis with an anterior 3.5-mm 6-hole plate alone and (2) the same anterior fixation supplemented posteriorly with a percutaneous partially threaded 7.0 or 7.3-mm iliosacral screw. Postoperative CT scans were reviewed to assess the reduction of the pelvic ring and the position of all implants. The patients were followed for a minimum of 6 months or until the fixation failed. Examined data included demographic factors, type of and time to fixation failure, and presence of malunion. Univariate and multivariate statistical analyses were completed.

RESULTS

One hundred and thirty-four patients met the inclusion criteria. Ninety-two (69%) underwent combined anterior and posterior fixation, and 42 (31%) had anterior fixation alone. The average age and duration of follow-up were 38 years and 7.2 months, respectively. Anterior plate fixation failed in 5 patients (5%) in the combined-fixation group and in 17 patients (40%) in the anterior-only group (p < 0.0001). Malunion was identified in 1 patient (1%) in the combined group and in 15 (36%) in the anterior-only cohort (p < 0.0001).

CONCLUSIONS

Our study indicated that use of an anterior plate and a supplemental posterior screw for fixation of APC-2 pelvic ring injuries significantly decreases the rate of anterior plate failure and malunion compared with use of an anterior plate alone. The potential for selection and detection bias introduced by our study design limited the strength of this conclusion.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Percutaneous fixation of traumatic pubic symphysis diastasis using a TightRope and external fixator versus using a cannulated screw

Background

The aim of the study was to introduce a new percutaneous technique for the treatment of traumatic pubic symphysis diastasis using a TightRope and external fixator. A comparison between this technique and percutaneous fixation using a cannulated screw was performed.

Methods

From January 2009 to December 2013, 26 patients with type II traumatic pubic symphysis diastasis were treated at two level 1 regional trauma centers. Among them, 10 patients were treated with a percutaneous TightRope and external fixator and 16 patients were treated with percutaneous cannulated screw fixation. Functional outcomes were evaluated using the Majeed scoring system. Patient satisfaction was evaluated using the modified visual analog scale. Radiological results were assessed based on the width of pubic symphysis preoperatively, immediately postoperatively, and at the final follow-up. Postoperative complications were also recorded.

Results

There were no significant differences between the groups in Majeed scores and patient satisfaction (p > 0.05). There were no significant differences in the width of pubic symphysis preoperatively, immediately postoperatively, and at the final follow-up (p > 0.05). No significant differences were found regarding infection, fixation failure, or the need for revision surgery (p > 0.05).

Conclusions

The new percutaneous technique using a TightRope and external fixator is a successful alternative for the treatment of type II traumatic pubic symphysis diastasis, which results in similar outcomes comparing to percutaneous cannulated screw fixation.

Percutaneous iliosacral fixation in external rotational pelvic fractures. A biomechanical analysis

INTRODUCTION

Although the gold standard in open book pelvic fractures remains the pubic symphysis (PS) plate fixation, the clinical outcomes are not satisfactory, despite the excellent anatomical reduction assessed radiologically. Some authors suggest that residual instability of the posterior pelvic elements may be responsible for the chronic pain and the early osteoarthritic changes in the sacroiliac joint (SIJ).

OBJECTIVE

To evaluate whether the isolated posterior fixation with one or two iliosacral screws (ISSs) is sufficient to provide adequate stability for the treatment of Burgess Young APC-II (YB APC-II) type of pelvic ring injuries.

METHODS

Biomechanical experimental study using 7 fresh human pelvises, where an YB APC-II pelvic injury was previously implemented. The isolated posterior fixation of the pelvic ring with 1 or 2 ISSs directed in the S1 vertebra body was analysed in each specimen following an axial load of 300N. The different displacement of the SIJ and of the PS were analysed in all three spatial axes, using the validated optical measurement system 3D PONTOS 5M. A multivariate version of Friedman test (non-parametric ANOVA for repeated measures) was performed.

RESULTS

The isolated fixation of the SIJ with 1 ISS did not show any differences with respect to the intact pelvis (p=0.851). Regarding the PS, both type of fixations (with 1 or 2 ISSs) confirmed an acceptable correction and adequate control of the PS even though with some differences compared to the intact pelvis (p=0.01). The presence of the second ISS found not to offer any significant additional benefit. The three-dimensional analysis of the behaviour of the pelvic elements, in these two different types of fixation, did not show any statistical significant differences (p=0.645).

CONCLUSION

The posterior fixation with ISS can represent an alternative option for treatment of pelvic injuries associated with rotational instability. Further prospective clinical studies are necessary to determine, the influence of the residual pubic symphysis mobility in the every day life, when the above-mentioned technique is applied.

[Unilateral triangular lumbopelvic stabilization: indications and techniques]

Operative fixation has become treatment of choice for unstable sacral fractures. Osteosynthesis for these fractures results in loss of reduction in up to 15%. Vertical sacral fractures involving the S1 facet joint (Isler 2 and 3) may lead to multidirectional instability. Multidirectional instability of the posterior pelvic ring and lumbopelvic junction may be stabilized and forces balanced by a so-called lumbopelvic triangular fixation. Lumbopelvic triangular fixation combines vertical fixation between the lumbar vertebral pedicle and the ilium, with horizontal fixation, as an iliosacral screw or a transiliacal plate osteosynthesis. The iliac screw is directed from the posterior superior iliac spine (PSIS) to the anterior inferior iliac spine (AIIS). Thereby, lumbopelvic fixation decreases the load to the sacrum and SI joint and transfers axial loads from the lumbar spine directly onto the ilium. Triangular lumbopelvic fixation allows early full weight bearing and therefore reduces prolonged immobilization. The placement of iliac screws may be a complex surgical procedure. Thus, the technique requires thorough surgical preparation and operative logistics. Wound-related complications may occur. Preexisting Morell-Lavalée lesions increase the risk for infection. Prominent implants cause local irritation and pain. Hardware prominence and pain are markedly reduced with screw head recession into the PSIS.

Examination under anesthetic for occult pelvic ring instability

OBJECTIVE

To describe the technique and results of stress examination with fluoroscopy under anesthesia (EUA) to determine stability and the need for operative stabilization of traumatic pelvic ring injuries.

DESIGN

Retrospective chart and radiographic review.

SETTING

Level I trauma center.

SUBJECTS

Skeletally mature patients with traumatic incomplete posterior pelvic ring injuries.

METHODS

Patients were consented for EUA if preoperative radiographs and computed tomographic scanning of the pelvis demonstrated an incomplete injury to the posterior pelvic ring (Orthopaedic Trauma Association [OTA] 61-B type injuries). Patients with nondisplaced anterior compression fractures of the sacral ala without internal rotation or a fracture line exiting the posterior cortex were excluded from this analysis. Similarly, skeletally immature patients or those with complete instability of the pelvic ring (OTA 61-C type injuries) were excluded. All patients meeting inclusion criteria were taken to the operating room, anesthetized, and placed in the supine position for stress examination (EUA) of the pelvic ring using intraoperative dynamic fluoroscopy. Examination consisted of a resting static film followed by internal rotation, external rotation, and push-pull maneuvers of both lower extremities. Each of these maneuvers was performed using the anteroposterior, inlet, and outlet projections, providing a total of 15 distinct images for each patient's examination. The preoperative classification of the pelvic ring injury was then accepted or redefined based on the amount of rotational and translational instability in the axial, coronal, and sagittal planes. The decision to proceed with anterior and/or posterior operative reduction and stabilization was subsequently based on the degree of pelvic ring instability noted during the EUA.

RESULTS

A total of sixty-eight patients underwent an EUA of their pelvis by the senior author. Fifty males and 18 females with an average age of 35 years comprised the study group. In all, 37 anteroposterior compression (APC or OTA 61-B1) injuries and 31 lateral compression (LC or OTA 61-B2) injuries were evaluated. Of the 14 pelvic ring injuries initially classified as an APC-1, seven (50%) were deemed stable and treated nonsurgically, whereas seven (50%) were felt to have sufficient instability (an occult APC-2) to warrant treatment with anterior fixation based on EUA. Of the 23 injuries initially classified as an APC-2, all but one required surgical fixation: 13 (57%) were treated with anterior fixation alone (APC-2a), whereas nine (39%) were treated with anterior fixation and supplemental iliosacral screw placement (APC-2b) based on the degree of instability noted during the EUA. Of the 20 injuries initially classified as an LC-1, 13 (65%) were stable and treated nonsurgically (LC-1a), whereas seven (35%) were treated with anterior and/or posterior stabilization (LC-1b) based on the degree of instability noted during the EUA.

CONCLUSIONS

The reported incidence of poor functional outcomes associated with pelvic fracture may be attributable, in part, to inadequate treatment of misdiagnosed injuries and chronic instability and/or malunion. Performing an examination under anesthesia with dynamic stress fluoroscopy as described in this series revealed occult instability in 50% of presumed APC-1 injuries, 39% of APC-2 injuries, and 37% of LC-1 injuries. We propose a modification to the Young-Burgess Classification system to reflect the dynamic component of pelvic ring instability disclosed on EUA as follows: APC-2a for those injuries requiring anterior only fixation, APC-2b for those injuries that may require treatment with anterior and posterior fixation, LC-1a for those injuries that are stable and do not require internal fixation, and LC-1b for those lateral compression injuries that may require treatment with internal fixation. We conclude that pelvic EUA merits further analysis as an important diagnostic tool that may provide additional information regarding instability of the pelvic ring.

Management outcomes in pubic diastasis: our experience with 19 patients

Background

Pubic diastasis, a result of high energy antero-posterior compression (APC) injury, has been managed based on the Young and Burguess classification system. The mode of fixation in APC II injury has, however, been a subject of controversy and some authors have proposed a need to address the issue of partial breach of the posterior pelvic ring elements in these injuries.

Methods

The study included a total of 19 patients with pubic diastasis managed by us from May 2006 to December 2007. There was a single patient with type I APC injury who treated conservatively. Type II APC injuries (13 patients) were treated surgically with symphyseal plating using single anterior/superior plates or double perpendicularly placed plates. Type III injuries (5 patients) in addition underwent posterior fixation using plates or percutaneous sacro-iliac screws. The outcome was assessed clinically (Majeed score) and radiologically.

Results

The mean follow-up was for 2.9 years (6 months to 4.5 years). Among the 13 patients with APC II injuries, the clinical scores were excellent in one (7.6%), good in 6 (46.15%), fair in 4 (30.76%) and poor in 2 (15.38%). Radiological scores were excellent in 2 (15.38%), good in 8 (61.53%), fair in 2 (15.38%) and poor in one patient (7.6%). Among the 5 patients with APC III injuries, there were 2 patients each with good (50%) and fair (50%) clinical scores while one patient was lost on long term follow up. The radiological outcomes were also similar in these. Complications included implant failure in 3 patients, postoperative infection in 2 patients, deep venous thrombosis in one patient and bladder herniation in one of the patients with implant failure.

Conclusions

There is no observed dissimilarity in outcomes between isolated anterior and combined symphyseal (perpendicular) plating techniques in APC II injuries. Single anterior symphyseal plating along with posterior stabilisation provides a stable fixation in type III APC injuries. Limited dissection ensuring adequate intactness of rectus sheath is important to avoid long term post-operative complications.

Stress radiograph to detect true extent of symphyseal disruption in presumed anteroposterior compression type I pelvic injuries

BACKGROUND

The differentiation between anteroposterior compression (APC)-I and APC-II pelvic fracture patterns is critical in determining operative versus nonoperative treatment. We instituted a protocol in which a stress examination was performed for patients presenting with an APC-I injury diagnosed with static radiographs to reveal the true extent of the injury.

METHODS

During a 4-year study period, we performed 22 stress radiographs in patients with a presumed APC-I injury, which showed symphyseal diastasis ≥ 1.0 cm but <2.5 cm on initial anteroposterior (AP) radiographs of the pelvis or on axial images of the pelvis on computed tomography (CT) scans. In the operating room, a radiopaque marker of known diameter was placed on the skin over the pubic symphysis. A direct AP load was manually applied to both anterior superior iliac spines, and diastasis of the pubic symphysis was measured on stress fluoroscopic images.

RESULTS

The mean distance of symphyseal diastasis was 1.8 cm on the AP radiographs, 1.4 cm on the CT scans, and 2.5 cm on fluoroscopic images under a stress examination. Six of 22 patients (27.2%) demonstrated a symphyseal diastasis of >2.5 cm during the stress examination, which changed their treatment from nonoperative to operative.

CONCLUSIONS

Measurements of symphyseal diastasis can significantly vary depending on the radiographic modality (CT vs. plain films) and during application of a stress force. The use of stress examination under general anesthesia in the acute setting of pelvic injury can be beneficial in accurately diagnosing the severity of injury and choosing appropriate treatment.