Date: Sat, 15 Feb 2003 00:44:44 +0530

Subject: Unstable pelvic injury with spine injury

Friends,

I present this case for your critical comments.

35 year old male brought following a heavy log falling on him. Was taken to a local hospital where he was reported to be in shock, was given fluid resuscitation and then transferred to us.

On admission patient was hypotensive. Evaluation revealed him to be having an unstable pelvic ring injury, D12 vertebral body fracture, free fluid in the abdomen and a suspected urinary bladder injury. After his haemodynamic status was better he was taken up for an emergency laparotomy (midline approach). Though there was free blood stained fluid in the peritoneum no hollow viscus injury or other organ damage was noted. Urinary bladder contusion present but no tear. At he same sitting the anterior pelvic ring was stabilised using reconstruction plates through an extended Pfannensteil approach. After a couple of days the posterior ring was stabilised using reconstruction plates (posterior approach). The spine was not interfered surgically since this was inherently stable and there were no neurological findings. The posterior wound grumbled for some time and settled down. He was kept in bed but allowed free turning in bed.

The X rays and few CT reconstructions attached. Kindly give your valuable comments. What all would have been better ways of management?

Dr.T.I. George, Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital, Trichur, S.India.


Reply at: Orthopaedic Trauma Association forum

Date: Fri, 14 Feb 2003 12:24:56 -0800

From: Chip Routt

If he heals and doesn't hurt, there is no better way!!!

There are many effective methods for managing this injury.

You can realign the anterior fractures with either closed or open techniques.

Closed manipulation requires early patient referral/surgical intervention, and good quality intraoperative fluoroscopy.

Medullary ramus screws can stabilize the ramus fractures...either antegrade or retrograde direction. They essentially eliminate "surface exposure" which should diminish infection risk. The medullary screws have been equally "strong" when compared to plating techniques in both lab and clinical series.

The iliac fracture with associated sacroiliac anterior disruption (some call this a "crescent fracture-dislocation") might allow manipulative reduction and percutaneous iliosacral screw fixation....it's difficult to know if an iliosacral screw would work without a routine 2-D CT to examine. It might not be possible for this specific fracture because of it's location. The screw must connect the unstable iliac component to the sacrum...some have used iliosacral screws for these "more anterior" iliac fracture patterns, but the iliosacral screw is mistakenly inserted through the stable iliac posterior (crescent fragment) component into the sacrum...that screw doesn't accomplish much....don't do that!

As far as open techniques, this injury pattern also can be reduced and stabilized using the lateral "window" of an ilioinguinal exposure. This approach would save time since both the Pfannenstiel and lateral window can be performed with the patient supine. You can even open both, then manipulate the ramus and iliac-SI injuries together.

Some believe that the lateral window of the ilioinguinal exposure would have a lower wound complication rate than a posterior exposure.

You could manage it effectively with traction.

You could try an anterior frame alone, or with traction.

You might also have success using a frame and iliosacral screws (assuming the iliosacral screws would be OK for this particular fracture).

Many treatment options for this injury pattern-

Chip

PS- I enclose two images from a closed reduction and percutaneous fixation procedure in a similar pattern...but our patient had a much smaller intact/stable posterior iliac "crescent" segment, so iliosacral screws were very effective in his particular pattern.


Date: Sat, 15 Feb 2003 18:23:25 +0530

From: DR T I GEORGE

Hi Chip,

Thanks for the educative reply. In fact I think I had seen the images you have now posted(or similar images) in an earlier OTA discussion and wanted to ask a few questions but never got down to it.

You wrote: "Medullary ramus screws can stabilize the ramus fractures...either antegrade or retrograde direction. They essentially eliminate "surface exposure" which should diminish infection risk. The medullary screws have been equally "strong" when compared to plating techniques in both lab and clinical series".

Are there any online references available on these surgical techniques? Which are the companies marketing this instrumentation?

You wrote: "As far as open techniques, this injury pattern also can be reduced and stabilized using the lateral "window" of an ilioinguinal exposure. "

Again are there any online references available for this and percutaneous iliosacral screw application techniques?

Dr.T.I. George, Consultant Orthopaedic Surgeon,
Polytrauma, Microvascular Surgery And Hand Surgery Unit,
Metropolitan Hospital, Trichur, S.India