Sequential reduction and fixation for windswept pelvic ring injuries (LC3) corrects the deformity until healed.

PURPOSE: The restoration, and fixation, of normal pelvic anatomy after a windswept type injury can be a difficult endeavor and our purpose is to describe a method to accomplish this. METHODS: A stepwise and sequential technique was utilized to effectively reduce and stabilize this injury pattern. By first closing down the open disruption posteriorly and fixing with a partially threaded SI screw, a stable platform was created upon which to work from and subsequently distract and reduce the contralateral side via an anterior internal fixator (seven), external fixator (one), or plate (one). This was followed by a fully threaded SI screw in the compression side of the sacral fracture to hold the distraction. Nine consecutive patients with LC3 (61-B3.2) were included in the study with an average FU of 15 months. RESULTS: The Keshishyan deformity index revealed an initial mean deformity of 0.0456 which was corrected to 0.0170 (postop) and 0.0181 at latest follow up. This entailed an average correction of 62 % at the latest follow up. The follow-up group was significantly different from pre-op (p = 0.0040), but not post-op (p = 0.6833). Furthermore, post-op was significantly different from pre-op (p = 0.0089). CONCLUSION: This is an effective method of correcting and maintaining reduction until healing for this relatively rare and difficult-to-treat injury pattern.

Combined Pelvic Ring Disruption and Acetabular Fracture: Outcomes Using a Sequential Reduction Protocol and an Anterior Subcutaneous Pelvic Fixator (INFIX).

OBJECTIVE: The purposes of this article were to (1) compare our combined pelvic ring and acetabular fracture patients' rate of mortality and Injury Severity Score (ISS) to those of patients with isolated injuries at our center and to those with combined injuries as reported in the literature, (2) describe our treatment algorithm using the INFIX for these combination injuries, and (3) report our patients' radiographic and functional outcomes. DESIGN: Retrospective IRB-approved case series and literature review. SETTING: US Level 1 Trauma Center. PATIENTS/PARTICIPANTS: Thousand six hundred ninety-seven with acetabular or pelvic ring injury, 174 patients with combination pelvic ring acetabular injuries, and 39 patients with 41 acetabular injuries treated with a surgical protocol. INTERVENTION: Pelvic ring reduction using INFIX and posterior fixation followed by acetabular reduction fixation. Anterior injury fixed with INFIX. MAIN OUTCOME: Mortality, ISS, pelvic reduction by Keshishyan index, acetabular reduction by the Matta criteria, and functional outcome by the Majeed score. RESULTS: Mortality was 5.7% and ISS was 12.5 for 174 combined injury patients. In the 39 patients with 41 injuries, excellent pelvic reduction was found in 39, and acetabular reduction was anatomic in 25 (61%), imperfect in 12 (29%), and poor in 4 (10%). Clinically 78% of the patients had good or excellent outcome and 22% had a fair or poor outcome. Nonanatomic acetabular reduction, persistent sciatic nerve palsy, and heterotopic ossification associated with poor clinical outcome. CONCLUSIONS: Our treatment protocol resulted in excellent pelvic reduction, anatomic acetabular reduction in 61% of patients, and 78% good to excellent clinical outcome. LEVEL OF EVIDENCE: Case series Level IV.

The Anterior Subcutaneous Pelvic Fixator (INFIX) in an Anterior Posterior Compression Type 3 Pelvic Fracture.

OBJECTIVES: The purpose of this video is to describe the equipment, anatomy, and surgical technique of anterior subcutaneous pelvic fixation (INFIX) using pedicle screws and a rod in an Anterior Posterior Compression 3 pelvic fracture, as well as how to distract in lateral compression fractures. METHODS: The equipment required includes standard spine pedicle screw sets with long screws, 70-110 mm in length, and 7 or 8 mm in diameter. The approach is a mini open and one needs to be familiar with the iliac oblique, obturator outlet, and obturator inlet views. The length of the screw is measured from the sciatic notch to the skin, and they are placed so that the head sits just below the skin. The rod is passed just under the skin along the bikini line and the construct compressed or distracted against a c-clamp while monitored with fluoroscopy. In Orthopaedic Trauma Association C type injuries, we leave c-clamps on the outside the screws to reinforce them or use monoaxial screws. The implants are removed at 3-6 months postop. RESULTS: The patients tolerate the implants and are able to sit and stand with out difficulty. Complications include lateral femoral cutaneous nerve irritation, heterotopic bone, loss of fixation if the implants are applied incorrectly. CONCLUSIONS: The INFIX procedure for anterior pelvic fixation is based on standard techniques that are familiar to the Orthopaedic Pelvic Surgeon including supraacetabular screws. Rod bending, rod passing, determining the ideal height of the screws, and distraction/compression maneuvers are demonstrated in this video.

Effect of Pelvic Binder Placement on OTA Classification of Pelvic Ring Injuries Using Computed Tomography. Does It Mask the Injury?

OBJECTIVES: To assess the diagnostic sensitivity of computed tomography (CT) in patients with an unstable pelvic ring injury after application of a pelvic binder. DESIGN: An institutional review board approved retrospective study from 2003 to 2010. SETTING: Level 1 trauma center. PATIENTS: Inclusion criteria were patients in our trauma database with AO/OTA B or C type pelvic ring injury, which first had an anterior-posterior pelvic x-ray followed by application of a pelvic circumferential compression device (PCCD), then a CT, and a fluoroscopic stress examination under anesthesia (FEUA) (used as gold standard). Of 867 patients, 43 met the inclusion criteria. INTERVENTION: A senior Orthopaedic Resident and Trauma Attendings assessed x-rays, CTs, and FEUAs. Binomial test was used to compare imaging against final diagnosis. RESULTS: In Anterior Posterior Compression/Vertical Shear (OTA 61-B1, 61-B3.1, 61-C) injury patterns, prebinder x-rays were diagnostic in 69.4% (CI, 51.9%-83.7%) of cases, compared with 50% (CI, 32.9%-67.1%) with CT + PCCD. The x-ray was superior to CT + PCCD for identification of the anterior pelvic injury (McNemar exact P = 0.0352). If x-ray and CT + PCCD were viewed in tandem, 83.3% (CI, 67.2%-93.6%) of classifications were in agreement with the FEUA. For lateral compression mechanisms, the binder did not effect of the sensitivity of the CT except in the open book component of an lateral compression 3 (61-B3.2) mechanism. CONCLUSIONS: The placement of a pelvic binder has the potential to mask the severity of unstable pelvic ring injuries when relying only on CT for diagnosis. Fluoroscopic manual pelvic stress examination under anesthesia is an essential adjunct when a binder is placed before imaging. LEVEL OF EVIDENCE: Diagnostic level III. See Instructions for Authors for a complete description of levels of evidence.

Patients with pelvic fractures from blunt trauma. What is the cause of mortality and when?

BACKGROUND: Mortality in patients sustaining pelvic fractures has been reported to be 4% to 15%. We sought to investigate the cause of death based on timing and evaluate if type of fracture and Injury Severity Score have an influence on the survival time. METHODS: Sixty-nine patients of eight hundred sixty seven with a pelvic fracture who died during their hospital admission were included. Fractures were classified using the Arbeitsgemeinschaft Osteosynthesefragen/Orthopaedic Trauma Association system. Cause determined by autopsy in 48/69. RESULTS: The leading cause of death within 6 hours was abdominal and pelvic hemorrhage; 6 to 24 hours head injury, and greater than 24 hours multiple organ dysfunction syndrome. Survival time did not correlate between fracture type (P < .12) or Injury Severity Score. Only 2 patients died of isolated pelvic hemorrhage. CONCLUSIONS: Despite the advances made in acute management of the traumatized patient in the emergency department, mortality is unavoidable in a small group of patients with hemorrhage being the commonest cause of early death but isolated pelvic hemorrhage rare.