Pelvic Fractures Treatment & Management
- Author: George V Russell Jr, MD; Chief Editor: William L Jaffe, MD more...
Pelvic fractures historically have been treated nonoperatively. Operative management of unstable pelvic injuries has increased because of several factors, including the following:
Improved and coordinated treatment of polytraumatized patients
Improved anesthetic techniques, including blood salvage systems
Advances in intraoperative fluoroscopic imaging techniques
Standardized pelvic implant systems
Better understanding of injury and deformity patterns
Operative management of unstable pelvic ring injuries allows earlier patient mobilization, thereby decreasing complications associated with recumbency. Operative management also allows correction and prevention of significant pelvic deformities, improving clinical outcomes.
Controversies in treating pelvic fractures revolve around the issue of pelvic stability. Definitions of pelvic stability are vague and hard to quantify in a clinical setting. As a result of a nebulous definition of pelvic stability, determining the type and amount of pelvic stabilization is also controversial. Bucholtz and Peters stated the problem well : "As a general rule, if a posterior ring injury is nondisplaced or impacted, the pelvis is probably stable. If there is a superior or anteroposterior displacement of the hemipelvis of 1 cm or more, the pelvis is clearly unstable. All injuries between these 2 extremes may or may not be stable and must be evaluated and treated individually."
Most clinicians responsible for the care of patients with pelvic ring injuries will base instability on the physical exam. Instability is defined as the inability to resist deformation with physiological loading.
The future of pelvic fracture management will likely involve advances in imaging techniques. Except for major pelvic disruptions, the state of the posterior ligamentous structures is inferred from clinical findings, plain radiographs, and computed tomography (CT) scans. Magnetic resonance imaging (MRI) may one day have a role in visualizing the posterior ligamentous structures, allowing these injuries to be better defined.
Computer-assisted surgery is being developed and studied at various locations. This approach comprises robotics, image-guided surgical devices, surgical navigation systems, preoperative planners and simulators, and augmented-reality or hybrid-reality computer interfaces. Computer-assisted surgery has been used successfully around the pelvis to assist with pelvic osteotomies. As the technology improves and familiarity grows with these techniques, it will likely be used in the management of pelvic fractures.
Nevertheless, surgeons should not assume that computer-assisted surgery and robotics can substitute for their personal knowledge of pelvic injuries and radiographic correlations. At present, the pelvic anatomy and its injury patterns are best understood, and their treatments best directed, by knowledgeable humans rather than by computer software.
Initial therapy in the acutely injured patient centers on the ABCs, as recommended by the Advanced Trauma Life Support (ATLS) protocols published by the American College of Surgeons. The following mnemonic defines the specific, ordered, prioritized evaluations and interventions that should be followed in injured patients:
Airway with cervical spine control
Disability or neurologic status
Exposure (undress) with temperature control
After initial resuscitation and stabilization, other non-life-threatening injuries are evaluated and managed appropriately. Following these guidelines, under the direction of a trauma surgeon or general surgeon, patient treatment is optimized.
Management of pelvic fractures in the immediate setting is centered on controlling life-threatening injuries, particularly severe hemorrhage. Several techniques have been used to control hemorrhage. These techniques are based on decreasing the volume of the pelvis, thereby limiting the amount of blood that can escape into the pelvic cavity.
Perhaps the simplest method to decrease pelvic volume is to wrap a sheet securely around the patient's pelvis. External fixators and other external pelvic clamps have been advocated to control pelvic volume, with the added benefit of providing bony stability, thereby preventing fracture movement and dislodgment of clots.
Pneumatic antishock garments also have been used to control hemorrhage associated with pelvic fractures. Care must be taken in using pneumatic antishock garments because they increase intramuscular and intrathoracic pressure, potentially leading to compartment syndrome and respiratory compromise distress. Pneumatic antishock garments are contraindicated in patients with pulmonary edema and/or diaphragmatic rupture.
The primary goal for the treatment of pelvic fractures in the acute setting is to provide early stable fixation to allow patient mobilization. Several studies of early pelvic fracture treatment have demonstrated beneficial effects, such as decreased blood transfusion requirements, decreased systemic complications, decreased hospital stays, and improved patient survival.[19, 20] Secondary considerations for operative management of pelvic fractures in the acute setting are the correction or prevention of significant pelvic translational and rotational deformities that have been associated with poorer clinical outcomes.[4, 16, 42]
Approaches to specific fractures
Symphysis pubis disruptions
Disruptions of the symphysis pubis are typically described as resulting from an anterior or posterior force impacting the pelvis; however, laterally directed compressive forces also have been implicated in creating symphyseal disruptions.[16, 30]
Indications to stabilize symphysis pubis disruptions operatively are determined by the amount of instability between the pubic bones. Several authors have recommended operative stabilization when the pubic diastasis is greater than 2.5 cm, on the basis of experimental evidence demonstrating that pubic bone displacement greater than 2.5 cm implies rupture of the anterior sacroiliac, sacrospinous, and sacrotuberous ligaments, rendering the pelvis rotationally unstable.[16, 29]
Letournel recommended operative stabilization of symphyseal disruptions when the pubic diastasis measures greater than 1.5 cm. Routt et al also noted that children and people of smaller stature may demonstrate rotational pelvic instability with pubic diastases less than 2.5 cm. It has been observed that a symphysis pubis diastasis may increase after administration of general anesthesia, implying that plain radiographs may underestimate the actual deformity because of associated muscle spasm.
Treatment options for symphyseal disruptions consist of external fixation or more mechanically sound open reduction with internal fixation (ORIF). Anterior pelvic external fixation can be used in patients with small symphyseal disruptions with incomplete posterior ligamentous injury.[30, 43, 44] The use of an anterior external fixator is potentially beneficial because it avoids operative exposures, potential bleeding from venous plexus injuries, and bladder perforation associated with open stabilization.
The external fixator is also useful to avoid wound contamination when suprapubic catheters are in place for the treatment of urinary bladder disruptions. The external fixator should remain in place until healing is demonstrated, which usually occurs between 6 and 12 weeks postoperatively.[43, 44] External pelvic fixation is cumbersome for patients and is associated with pin-track infections and even iliac osteomyelitis.
ORIF is preferred for unstable symphyseal injuries; it avoids the inconvenience of wearing and removing an external fixator. Surgical stabilization is performed through a Pfannenstiel surgical exposure, or an extension of a midline exposure may be used. Tenaculum clamps, Farabeuf clamps, and pelvic reduction clamps may be used to reduce the pubic diastasis.
Implants commonly used to stabilize symphyseal disruptions are 3.5-mm reconstruction plates, 4.5-mm reconstruction plates, 3.5-mm low-contact dynamic compression plates, and 4.5-mm low-contact dynamic compression plates. Regardless of the plate used, at least two screws should be placed on each side of the defect to prevent subsequent rotatory deformities. The larger plates do not fit the symphyseal area well; for this reason, 3.5-mm pelvic reconstruction plates are preferred.
Pubic ramus fractures
Pubic ramus fractures occur as parasymphysial fractures, midramus fractures, and pubic root fractures in association with distraction and compression injuries of the pelvis. Displacement of pubic ramus fractures may cause impingement or laceration of the bladder, vagina, and perineum, and for these reasons, operative management may be considered. Operative treatment of pubic rami fractures is indicated to provide additional pelvic ring stability in association with posterior pelvic ring fixation. Stabilization of pubic rami fractures also may be considered in fractures involving the obturator neurovascular canal with accompanying neurologic injury.
Treatment options for pubic ramus fractures include external fixation, percutaneous screw fixation, and ORIF. External fixation with either multiple pins or single pins in each hemipelvis may be used successfully in conjunction with stabilization of posterior ring injuries to impart additional stability to the pelvic fixation construct.[44, 45] External fixation for pubic ramus fractures is indicated to impart additional stability after posterior pelvic ring repair and also when percutaneous or open treatment is contraindicated.
Intramedullary fixation of the pubic ramus has been described for treatment of pubic ramus fractures.[12, 46] Intramedullary pubic ramus fixation with a 4.5-mm cortical screw has demonstrated fixation strength equivalent to plate fixation and has demonstrated good results in clinical settings.[38, 47] Intramedullary stabilization of ramus fractures may be performed with either a percutaneous or open technique with either antegrade or retrograde screw placement in the pubic ramus. Extramedullary plate fixation is another option to stabilize pubic ramus fractures after open reduction and usually is achieved with 3.5-mm pelvic reconstruction plates.
Iliac wing fractures
Iliac wing fractures are caused by forces applied directly to the iliac wing. Simple fracture patterns without associated pelvic ring instability are managed with nonoperative measures. Comminuted iliac wing fractures are caused by high-energy injuries, and are frequently accompanied by severe soft-tissue injuries, including open wounds.
Indications for operative management of iliac wing fractures include associated skin abnormalities, significant closed degloving injuries, and open wounds. Severely displaced or comminuted iliac wing fractures, unstable iliac fractures that preclude adequate pulmonary function secondary to pain, bowel herniation or incarceration within the fracture, and fractures associated with unstable pelvic ring injuries are other indications for ORIF.[30, 48] Preoperative pelvic angiograms are recommended for fractures involving the greater sciatic notch.
The lateral window of the ilioinguinal surgical exposure is used to access iliac wing fractures. After fracture exposure, tenaculum clamps, Farabeuf clamps, and Schanz pins used as joysticks are used to obtain fracture reduction. Fracture reduction is maintained with medullary lag screws in combination with pelvic reconstruction plates for definitive stabilization. For patients with open iliac fractures, the fixation construct should rely on medullary screws in order to seclude the implants from contamination.
Crescent fractures—fractures of the posterior ilium extending from the iliac crest into the greater sciatic notch—are associated with an articular dislocation of the anterior sacroiliac (SI) joint. They commonly result after later al compression (LC) injuries to the iliac wing but also may occur secondary to anteriorly or posteriorly directed forces.[29, 30]
Crescent fractures typically result in a stable posterior iliac fragment because of the attachment of the intact posterior SI ligaments, whereas the iliac component is rotationally unstable. When viewed laterally, the posterior iliac stable segment is crescent-shaped; hence the terminology. Surgical stabilization is indicated because of the inherent instability of the iliac wing component of the fracture and the dislocation of the SI joint.
Crescent fractures may be treated with the patient positioned either prone or supine, depending upon associated pelvic ring injuries, acetabular fractures, soft-tissue injuries, and the location of the crescent fracture. Fractures treated from the prone position are exposed with a vertical paramedian dorsal surgical approach, allowing direct reduction of the iliac fracture and indirect reduction of the SI joint. The iliac fracture is visualized directly, reduced with clamps, and stabilized with lag screws and 3.5-mm reconstruction plates along the iliac wing. Percutaneously placed iliosacral screws also may be used to supplement fixation.
Treatment of crescent fractures with the patient in the supine position allows direct reduction of the SI joint and indirect reduction of the iliac fracture. The lateral window of the ilioinguinal surgical exposure is used to access the SI joint. After the SI joint is visualized and debrided, reduction is performed under direct visualization with a combination of clamps, external fixators, and, occasionally, a femoral distractor used in compression. The SI joint is stabilized with iliosacral screws, 3.5-mm reconstruction plates placed perpendicular to one another, or both used in combination.
Isolated percutaneous treatment of crescent fractures using iliosacral screw fixation can be used if the posterior iliac fracture fragment is small, the unstable iliac wing component can be reduced with closed manipulative means, and the sacral safe zone is large enough to accommodate an iliosacral screw. This technique can be used with either prone or supine positioning using well-described techniques for placement of iliosacral screws.[51, 52]
Sacroiliac joint disruptions
SI joint disruptions occur as a result of an anteriorly or posteriorly directed force to the pelvis associated with symphysis pubis disruptions or pubic ramus fractures.[3, 4, 28] Incomplete disruptions of the SI joint typically are characterized by rupture of the anterior SI ligaments with a concurrent symphyseal disruption of less than 2.5 cm. These injuries are not associated with vertical instability and may be managed nonoperatively, with external fixation, or with ORIF.[16, 44]
Complete disruptions or dislocations of the SI joint are associated with rupture of the anterior and posterior SI joint ligaments. A rotationally and/or vertically unstable pelvis characterizes these injuries. Because of the poor results with persistent SI joint subluxations and dislocations, surgical reduction and stabilization is recommended.
Open treatment of SI joint disruptions can be performed from either the supine or the prone position. Stabilization in the supine position usually is achieved using the lateral window of the ilioinguinal surgical exposure. After debridement of the joint space, the dislocation is reduced. Care must be taken with exposure across the SI joint to avoid excessive medial dissection and prevent injury to the L5 nerve root. Distal ipsilateral femoral traction, Schanz pins within the ilium, tenaculum clamps, Farabeuf clamps, pelvic reduction clamps, and a femoral distractor used in compression may all be helpful in reducing SI joint disruptions.
Stabilization is achieved with either 3.5- or 4.5-mm pelvic reconstruction plates placed perpendicular to one another across the SI joint. Plates should be contoured carefully to avoid distraction at the inferior portion of the SI joint. The S1 nerve root is at risk in drilling and inserting a screw within the sacral ala, and fluoroscopic guidance is recommended.
Stabilization of SI disruptions from the prone position uses a vertical paramedian dorsal surgical exposure; however, one must be wary of significant wound problems that may develop when posterior exposures are used in a compromised soft-tissue envelope.[19, 44] Unlike anterior surgical exposures, reduction of the SI joint is performed indirectly because visualization is compromised as the joint is brought into reduction. Reduction is verified manually by palpation of the anterior aspect of the SI joint through the greater sciatic notch, and radiographically with intraoperative fluoroscopic imaging.
Reduction of the dislocated ilium to the sacrum may be assisted with clamps placed through the greater sciatic notch clamping the posterior iliac wing to the sacral ala.[51, 54] Stabilization is obtained with combinations of transiliac plates using either pelvic reconstruction or dynamic compression plates, transiliac screws, and iliosacral screws.
Use of iliosacral screws has gained popularity for stabilization of SI joint disruptions. Percutaneously placed iliosacral screws have been used after both open and closed reduction of SI joint disruptions. Iliosacral screws may be placed in either the prone or supine position with good results.[51, 52, 55] In using percutaneous techniques for posterior ring stabilization, it is helpful to reduce and stabilize the anterior pelvic ring injuries; these measures indirectly reduce the posterior ring, thereby allowing safe iliosacral screw placement.
Careful examination of plain radiographs and CT scans is essential in evaluating sacral morphology and planning for safe iliosacral screw placement. Cannulated iliosacral screws are inserted under fluoroscopic guidance with the help of using inlet, outlet, and lateral sacral images.[38, 56]
Others prefer solid iliosacral screw placement, with which the tactile sensation of the drill bit engaging the sacral ala and sacral body is used to assist fluoroscopic imaging in safe placement of iliosacral screws.[51, 57] Still others favor CT-guided placement of iliosacral screws.[58, 59] Each technique has its advantages and associated potential problems, but each demands that the surgeon understand the local anatomy and achieve accurate reductions.
Sacral fractures frequently occur with pelvic ring injuries. Sacral fractures commonly are classified by location, as follows :
Type I fractures involve the sacral ala
Type II fractures involve the sacral foramina
Type III fractures involve the central portion of the sacrum
Roy-Camille has further subclassified central sacral fractures.
Operative stabilization is indicated for the following sacral fractures:
Those that are displaced
Those that lend themselves to pelvic ring instability
Those with foraminal debris causing a neurologic deficit
Sacral fractures usually are treated by indirect reduction techniques unless a need for foraminal decompression is present or an acceptable reduction cannot be obtained by closed manipulative means. Open treatment is performed in the prone position via a vertical paramedian dorsal surgical exposure. Direct access to the posterior sacrum is achieved by elevating the paraspinal muscles from the sacrum, whereby decompression of sacral foramina may be accomplished.
After fracture reduction, stabilization is obtained with transiliac bars, transiliac screws, transiliac plates, or iliosacral screws. Despite the implant, care must be taken not to overcompress the sacral fractures and potentially create an iatrogenic sacral nerve root injury.
Iliosacral screws may be placed in the supine or prone position to stabilize sacral fractures after closed manipulative means. Reduction and stabilization of associated anterior fractures facilitate reduction of sacral fractures, allowing safe iliosacral screw placement. Contraindications for percutaneous iliosacral screw technique are an inability to obtain reduction of the sacral fracture, sacral dysmorphism, or fractures of neural foramina requiring debridement.
Neurodiagnostic monitoring should be considered when foraminal debris is present and/or foraminal decompression is undertaken. Several different types of monitoring have been used with good results, including somatosensory evoked potentials, continuous electromyography (EMG), and stimulus-evoked EMG.[54, 61, 62] Neurodiagnostic monitoring does not protect the patient from a surgeon with poor understanding of the anatomy and its radiographic correlations.
Preoperative traction to prevent large pelvic translations and provide patient comfort is a consideration for patients with displaced pelvic fractures. Skeletal traction is preferred in the ipsilateral distal femur if not contraindicated. Between 10 and 30 lb of traction is sufficient to meet the goals of provisional stabilization. Patients with injuries of the sciatic nerve should be splinted to avoid equinus deformities.
Deep venous thrombosis (DVT) prophylaxis, by either mechanical or pharmacologic means, is recommended in the preoperative setting. Subcutaneous heparin, low-molecular-weight heparin (LMWH), warfarin, and aspirin are all used for DVT prophylaxis. Compression hose and sequential compression devices also are used in combination with pharmacologic methods to prevent DVT formation. Inferior vena cava (IVC) filters are used occasionally when pharmacologic prophylaxis is contraindicated or a DVT has been detected. Consideration should be given to preoperative duplex ultrasonography, especially in patients with prolonged recumbency prior to surgery.
A screening hematocrit must be obtained, and the patient must have a type and crossmatch prior to surgery. Cell savers are valuable tools to decrease the need for blood transfusions and should be reserved in the preoperative period.
Patients with neurologic injuries require special consideration in the preoperative period. Sciatic nerve palsies must be recognized, and splinting of the ankle is required to prevent equinus contractures. Injuries to all, or portions of, the lumbosacral plexus may occur with pelvic ring injuries. When possible, these injuries should be clearly documented in the preoperative setting to avoid confusion about potential iatrogenic injuries. Neurodiagnostic monitoring may be desirable and should be arranged preoperatively if warranted.
If intraoperative fluoroscopy is to be used and the patient has ingested oral contrast, an anteroposterior (AP) pelvic radiograph is recommended preoperatively to ensure that fluoroscopic visualization is adequate. Residual contrast should be evacuated prior to surgery and a repeat AP pelvic radiograph performed after bowel evacuation.
Preoperative templating of plates to a skeletal model may prove beneficial by decreasing operating time and increasing operative efficiency. For example, transiliac plates are easily contoured to a skeletal model and after sterilization may be applied to the ilium with minor modifications as needed.
The operative table usually is chosen to allow intraoperative fluoroscopic imaging, and a radiolucent table is recommended. For supine positioning, a lumbosacral support is placed beneath the patient's back along the axis of the spine, which allows iliosacral screw insertions if needed. The arms are placed at 90° to the body on padded arm boards to allow proper positioning of the C-arm. If traction is to be used, a traction apparatus from the table can be used, or traction may be applied by hanging the weights over the side of the table.
Prone positioning is achieved on the same table wih the help of padded chest rolls, which relieve abdominal pressure and allow ventilation. Pads are placed anterior to the knees, and pillows are placed anterior to the legs to elevate the toes off the table. The arms are placed in a flying position with 45° of shoulder abduction and neutral shoulder elevation. The elbows are flexed to 90°, and the hands are positioned pronated on the arm boards.
If neurologic monitoring is used, the setup should be performed preoperatively. The technician should establish the workings of the setup, and baseline values should be obtained. An understanding should exist between the examiner and the anesthesiologist regarding the type of anesthetic agents to be used because neurologic recordings vary with certain anesthetics.
Portable postoperative AP, inlet, and outlet pelvic radiographs are obtained in the recovery room to assess pelvic ring reconstruction and implant safety. If these radiographs are of inferior quality, then consideration should be given to taking radiographs in the radiology department on discharge from the recovery room. Postoperative CT is recommended to assess pelvic ring reduction and implant safety, particularly when iliosacral screws are used.
Postoperative pain control is important for enhancing patient mobilization. Epidural narcotics provide excellent pain relief in the acute postoperative period; however, one must be aware of potential epidural bleeding with concurrent anticoagulation. Patient-controlled analgesia (PCA) machines work well to alleviate postoperative pain, and patients do not depend on nursing administration of narcotic analgesics. Long-acting oral narcotic medications may be useful as an adjunct to PCA to provide sustained pain control. After discontinuance of intravenous narcotic medications, both long-acting and short-acting oral narcotics are used to manage postoperative pain.
DVT prophylaxis is important postoperatively and should be managed aggressively. Mechanical methods, such as support stockings, work to decrease venous stasis, thereby decreasing the risk of DVT formation. Sequential compression devices also work to decrease venous stasis, but they also may have a role in stimulating the fibrinolytic system and tissue factor pathway inhibitor release.
Pharmacologic DVT prophylaxis consists of subcutaneous heparin, LMWH, warfarin, and aspirin. The choice of agent is beyond the scope of this discussion, but evidence suggests that combined mechanical and pharmacologic prophylaxes may result in greater protection than either alone. IVC filters may be placed perioperatively in patients in whom pharmacologic DVT prophylaxis and treatment are contraindicated and also in patients with documented DVTs.
Muscle ruptures and hernias
Muscle ruptures and hernias have been reported infrequently with pelvic ring injuries. Ryan noted that anteroposterior compression (APC) injuries were associated with avulsion of the medial portion of the rectus abdominis, which could give rise to ventral hernias. Ryan also noted an association of direct inguinal hernias with pubic ramus fractures occurring after disruption of the posterior wall of the inguinal canal. These are avoided when ORIF is selected for these fractures because the associated soft-tissue injuries are repaired at the time of closure. Bowel perforation, bowel entrapment, and bowel herniation also have been documented with comminuted iliac wing fractures.
Approximately 10% of all patients who sustain pelvic fractures also sustain neurologic injury. Most neurologic injuries involve the L5 and S1 nerve roots of the lumbosacral (LS) plexus; however, a significant number of patients also experience sexual dysfunction secondary to nerve injury of the lower sacral nerves.[28, 65] Associated sacral fractures account for many neurologic deficits with pelvic ring injuries. Denis reported a 28% incidence of nerve injury in patients after transforaminal sacral fractures and a 56% incidence of nerve injuries if the central sacrum was fractured.
The results of a retrospective review study on patients with pelvic fractures noted that while LS plexopathy was not associated with fracture location, the incidence and severity increases with the increasing number of anatomic fracture locations and with increased fracture instability. The results suggest that LS plexopathy may be the result of both indirect injury and simple direct compression by displaced bone.
Femoral nerve palsies may develop secondary to iliac hematoma and pubic ramus or certain acetabular pattern fracture displacements. Fractures of the pubic ramus at the superolateral aspect of the obturator foramen may cause obturator nerve injury. Lateral femoral cutaneous nerve injuries also may occur as a result of a direct blow to the lateral pelvic region in proximity to the anterior superior iliac spine and fracture displacement of this area.
Postoperative wound infection
The incidence of postoperative wound infection is low after anterior surgical exposures to the pelvis; however, the incidence increases with indwelling suprapubic catheters, colostomy, or drains in the region of the surgical incisions. Posterior surgical exposures are associated with higher instances of postoperative wound infection related to the soft-tissue injury, particularly those injuries associated with closed internal degloving injuries.[26, 44] Postoperative wound infections after percutaneous fixation techniques have a very low incidence, occurring only infrequently.
Nonunion after a pelvic fracture is uncommon, whereas malunion is more common. Pennal and Massiah evaluated 42 patients with delayed union and nonunion after pelvic fractures. They found that 15 of 16 patients who were treated surgically with stabilization and bone grafting demonstrated union. Nonunions in patients treated nonoperatively did not heal; these patients had poorer outcomes than the surgically treated group.
Matta and Tornetta treated 37 patients with pelvic malunions and nonunions. They highlighted the need for multiple-stage procedures to achieve satisfactory results, which were achieved in 32 patients, though 19% of the patients suffered complications.
Proximal deep vein thrombosis
Proximal DVT has been reported in as many as 61% of pelvic fracture patients without prophylaxis. Magnetic resonance venography has documented a 34% incidence of proximal DVT in patients with acetabular fractures who were treated prophylactically with low-dose heparin and mechanical compression devices. Documentation of proximal DVTs is important because these are most likely to embolize to the lungs.
The incidence of pulmonary embolism (PE) is 2-12% in patients with pelvic fractures, whereas fatal PE has been reported in 0.5-10% of patients sustaining pelvic fractures. Detection of proximal DVTs with venography or magnetic resonance venography is expensive and often impractical in the polytraumatized patient; therefore, the most effective treatment of patients with pelvic fractures is adequate prophylaxis.
GU complications occur in up to 37% of patients with pelvic ring injuries. The most common GU complications occurring with pelvic ring injuries are bladder disruptions and ureteral disruptions, particularly in male patients. Less commonly, the ureters and kidneys may be injured.
Dyspareunia and erectile dysfunction occur in approximately 29% of patients with pelvic ring injuries.[70, 71] Dyspareunia usually is caused by a displaced ramus fracture, causing pressure on the vaginal vault. Erectile dysfunction can have many causes, including vascular injury, neurologic injury, and psychological stress. A patient with erectile dysfunction should be referred to a urologist for evaluation and treatment.
Patients are mobilized according to their particular injury pattern, with a goal of full weightbearing by 3 months postoperatively. After discharge from the hospital, patients are seen in follow-up 2 weeks postoperatively for a wound check. They are seen again 6 weeks postoperatively for repeat clinical and radiographic examination. Further postoperative visits are scheduled at 3, 6, and 12 months postoperatively.
Huittinen VM, Slätis P. Postmortem angiography and dissection of the hypogastric artery in pelvic fractures. Surgery. 1973 Mar. 73(3):454-62. [Medline].
Schield DK, Tile M, Kellam JF. Open Reduction Internal Fixation of Pelvic Ring Fractures. J Orthop Trauma. 1991. 5(2):226.
Failinger MS, McGanity PL. Unstable fractures of the pelvic ring. J Bone Joint Surg Am. 1992 Jun. 74(5):781-91. [Medline].
McLaren AC, Rorabeck CH, Halpenny J. Long-term pain and disability in relation to residual deformity after displaced pelvic ring fractures. Can J Surg. 1990 Dec. 33(6):492-4. [Medline].
Pohlemann T, Bosch U, Gansslen A, Tscherne H. The Hannover experience in management of pelvic fractures. Clin Orthop. 1994 Aug. (305):69-80. [Medline].
Dunn AW, Morris HD. Fractures and dislocations of the pelvis. J Bone Joint Surg Am. 1968 Dec. 50(8):1639-48. [Medline].
Holdsworth F. Dislocation and fracture-dislocation of the pelvis. J Bone Joint Surg. 1948. 30-B:461-466.
Holm CL. Treatment of pelvic fractures and dislocations. Skeletal traction and the dual pelvic traction sling. Clin Orthop. 1973 Nov-Dec. 97:97-107. [Medline].
Watson-Jones R. Dislocations and fracture-dislocations of the pelvis. Br J Surg. 1938. 25:773-781.
Rice PL Jr, Rudolph M. Pelvic fractures. Emerg Med Clin North Am. 2007 Aug. 25(3):795-802, x. [Medline].
Burgess A, Jones A. Fractures of the pelvic ring. In: Rockwood C Jr, Green DP, Bucholtz R, Heckman J, eds. Fractures in Adults. Philadelphia, Pa: Lippincott-Raven; 1996:. 1575-1615.
Tile M. Anatomy. In: Tile M, ed. Fractures of the Pelvis and Acetabulum. Baltimore, Md: Williams & Wilkins; 1995:. 12-21.
Clemente C. Anatomy: A Regional Atlas of the Human Body. 2nd ed. Baltimore, Md: Urban and Schwarzenberg; 1981.
Hollinshead W. Pelvis. In: Anatomy for Surgeons: The Back and Limbs. 3rd ed. Philadelphia, Pa: Harper Rowe; 1982.
Anson B, ed. Morris' Human Anatomy. New York, NY: McGraw-Hill; 1966.
Tile M. Pelvic ring fractures: should they be fixed?. J Bone Joint Surg Br. 1988 Jan. 70(1):1-12. [Medline].
Gotis-Graham I, McGuigan L, Diamond T, et al. Sacral insufficiency fractures in the elderly. J Bone Joint Surg Br. 1994 Nov. 76(6):882-6. [Medline].
Melton LJ 3rd, Sampson JM, Morrey BF, Ilstrup D. Epidemiologic features of pelvic fractures. Clin Orthop. 1981 Mar-Apr. (155):43-7. [Medline].
Goldstein A, Phillips T, Sclafani SJ, et al. Early open reduction and internal fixation of the disrupted pelvic ring. J Trauma. 1986 Apr. 26(4):325-33. [Medline].
Latenser BA, Gentilello LM, Tarver AA, et al. Improved outcome with early fixation of skeletally unstable pelvic fractures. J Trauma. 1991 Jan. 31(1):28-31. [Medline].
Reilly MC, Zinar DM, Matta JM. Neurologic injuries in pelvic ring fractures. Clin Orthop. 1996 Aug. (329):28-36. [Medline].
Templeman D, Goulet J, Duwelius PJ, et al. Internal fixation of displaced fractures of the sacrum. Clin Orthop. 1996 Aug. (329):180-5. [Medline].
Sharma OP, Oswanski MF, Rabbi J, Georgiadis GM, Lauer SK, Stombaugh HA. Pelvic fracture risk assessment on admission. Am Surg. 2008 Aug. 74(8):761-6. [Medline].
American College of Surgeon's Committee on Trauma. Advanced Trauma Life Support (Course for Physicians). Chicago, Ill: 1993.
Peltier LF. Complications associated with fractures of the pelvis. J Bone Joint Surg Am. 1965 Jul. 47:1060-9. [Medline].
Hak DJ, Olson SA, Matta JM. Diagnosis and management of closed internal degloving injuries associated with pelvic and acetabular fractures: the Morel-Lavallee lesion. J Trauma. 1997 Jun. 42(6):1046-51. [Medline].
Watnik NF, Coburn M, Goldberger M. Urologic injuries in pelvic ring disruptions. Clin Orthop. 1996 Aug. (329):37-45. [Medline].
Huittinen VM, Slätis P. Nerve injury in double vertical pelvic fractures. Acta Chir Scand. 1972. 138(6):571-5. [Medline].
Burgess AR, Eastridge BJ, Young JW, et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma. 1990 Jul. 30(7):848-56. [Medline].
Routt ML Jr, Simonian PT, Swiontkowski MF. Stabilization of pelvic ring disruptions. Orthop Clin North Am. 1997 Jul. 28(3):369-88. [Medline].
Pennal GF, Tile M, Waddell JP, Garside H. Pelvic disruption: assessment and classification. Clin Orthop. 1980 Sep. (151):12-21. [Medline].
Dalal SA, Burgess AR, Siegel JH, et al. Pelvic fracture in multiple trauma: classification by mechanism is key to pattern of organ injury, resuscitative requirements, and outcome. J Trauma. 1989 Jul. 29(7):981-1000; discussion 1000-2. [Medline].
Young J, Burgess A. Radiologic Management of Pelvic Ring Fractures. Baltimore, Md: Urban and Schwarzenberg; 1987.
Nork SE, Jones CB, Harding SP, et al. Percutaneous stabilization of U-shaped sacral fractures using iliosacral screws: technique and early results. J Orthop Trauma. 2001 May. 15(4):238-46. [Medline].
Roy-Camille R, Saillant G, Gagna G, Mazel C. Transverse fracture of the upper sacrum. Suicidal jumper''s fracture. Spine. 1985 Nov. 10(9):838-45. [Medline].
Hilty MP, Behrendt I, Benneker LM, Martinolli L, Stoupis C, Buggy DJ, et al. Pelvic radiography in ATLS algorithms: A diminishing role?. World J Emerg Surg. 2008 Mar 4. 3:11. [Medline].
Gjertsen O, Schellhorn T, Nakstad PH. Fluoroscopy-guided sacroplasty: special focus on preoperative planning from three-dimensional computed tomography. Acta Radiol. 2008 Nov. 49(9):1042-8. [Medline].
Routt ML Jr, Nork SE, Mills WJ. Percutaneous fixation of pelvic ring disruptions. Clin Orthop. 2000 Jun. (375):15-29. [Medline].
Bucholtz RW, Peters P. Assessment of pelvic stability. In: Bassett FH, ed. Instructional Course Lectures. Rosemont, Ill: The American Academy of Orthopaedic Surgeons; 1988:. 119-27.
DiGioia AM 3rd. What is computer assisted orthopaedic surgery?. Clin Orthop. 1998 Sep. (354):2-4. [Medline].
Langlotz F, Bachler R, Berlemann U, et al. Computer assistance for pelvic osteotomies. Clin Orthop. 1998 Sep. (354):92-102. [Medline].
Slatis P, Huittinen VM. Double vertical fractures of the pelvis. A report on 163 patients. Acta Chir Scand. 1972. 138(8):799-807. [Medline].
Letournel E. Pelvic fractures. Injury. 1978 Nov. 10(2):145-8. [Medline].
Kellam JF. The role of external fixation in pelvic disruptions. Clin Orthop. 1989 Apr. (241):66-82. [Medline].
Tucker MC, Nork SE, Simonian PT, Routt ML Jr. Simple anterior pelvic external fixation. J Trauma. 2000 Dec. 49(6):989-94. [Medline].
Simonian PT, Routt ML Jr, Harrington RM, Tencer AF. Internal fixation of the unstable anterior pelvic ring: a biomechanical comparison of standard plating techniques and the retrograde medullary superior pubic ramus screw. J Orthop Trauma. 1994 Dec. 8(6):476-82. [Medline].
Simonian PT, Routt ML Jr, Harrington RM, Tencer AF. Box plate fixation of the symphysis pubis: biomechanical evaluation of a new technique. J Orthop Trauma. 1994 Dec. 8(6):483-9. [Medline].
Switzer JA, Nork SE, Routt ML Jr. Comminuted fractures of the iliac wing. J Orthop Trauma. 2000 May. 14(4):270-6. [Medline].
Borrelli J Jr, Koval KJ, Helfet DL. The crescent fracture: a posterior fracture dislocation of the sacroiliac joint. J Orthop Trauma. 1996. 10(3):165-70. [Medline].
Lange R, Webb L, Mayo K. Efficacy of the anterior approach for fixation of sacroiliac dislocations and fracture-dislocations. J Orthop Trauma. 1990. 4:220-221.
Matta JM, Saucedo T. Internal fixation of pelvic ring fractures. Clin Orthop. 1989 May. (242):83-97. [Medline].
Routt ML Jr, Simonian PT, Mills WJ. Iliosacral screw fixation: early complications of the percutaneous technique. J Orthop Trauma. 1997 Nov. 11(8):584-9. [Medline].
Simpson LA, Waddell JP, Leighton RK, et al. Anterior approach and stabilization of the disrupted sacroiliac joint. J Trauma. 1987 Dec. 27(12):1332-9. [Medline].
Moed BR, Ahmad BK, Craig JG, et al. Intraoperative monitoring with stimulus-evoked electromyography during placement of iliosacral screws. An initial clinical study. J Bone Joint Surg Am. 1998 Apr. 80(4):537-46. [Medline].
Schweitzer D, Zylberberg A, Córdova M, Gonzalez J. Closed reduction and iliosacral percutaneous fixation of unstable pelvic ring fractures. Injury. 2008 Aug. 39(8):869-74. [Medline].
Routt ML Jr, Simonian PT, Agnew SG, Mann FA. Radiographic recognition of the sacral alar slope for optimal placement of iliosacral screws: a cadaveric and clinical study. J Orthop Trauma. 1996. 10(3):171-7. [Medline].
Templeman D, Schmidt A, Freese J, Weisman I. Proximity of iliosacral screws to neurovascular structures after internal fixation. Clin Orthop. 1996 Aug. (329):194-8. [Medline].
Ebraheim NA, Rusin JJ, Coombs RJ, et al. Percutaneous computed-tomography-stabilization of pelvic fractures: preliminary report. J Orthop Trauma. 1987. 1(3):197-204. [Medline].
Nelson DW, Duwelius PJ. CT-guided fixation of sacral fractures and sacroiliac joint disruptions. Radiology. 1991 Aug. 180(2):527-32. [Medline].
Denis F, Davis S, Comfort T. Sacral fractures: an important problem. Retrospective analysis of 236 cases. Clin Orthop. 1988 Feb. 227:67-81. [Medline].
Vrahas M, Gordon RG, Mears DC, et al. Intraoperative somatosensory evoked potential monitoring of pelvic and acetabular fractures. J Orthop Trauma. 1992. 6(1):50-8. [Medline].
Webb LX, Araujo WD, Donofrio P. Continuous EMG monitoring for placement of percutaneous iliosacral screws. Orthop Trans. 1996. 20:134:
Montgomery KD, Geerts WH, Potter HG, Helfet DL. Practical management of venous thromboembolism following pelvic fractures. Orthop Clin North Am. 1997 Jul. 28(3):397-404. [Medline].
Ryan EA. Hernias related to pelvic fractures. Surg Gynecol Obstet. 1971 Sep. 133(3):440-6. [Medline].
Weis EB Jr. Subtle neurological injuries in pelvic fractures. J Trauma. 1984 Nov. 24(11):983-5. [Medline].
Jang DH, Byun SH, Jeon JY, Lee SJ. The relationship between lumbosacral plexopathy and pelvic fractures. Am J Phys Med Rehabil. 2011 Sep. 90(9):707-12. [Medline].
Pennal GF, Massiah KA. Nonunion and delayed union of fractures of the pelvis. Clin Orthop. 1980 Sep. (151):124-9. [Medline].
Matta JM, Tornetta P 3rd. Internal fixation of unstable pelvic ring injuries. Clin Orthop. 1996 Aug. (329):129-40. [Medline].
Geerts WH, Code KI, Jay RM, et al. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994 Dec 15. 331(24):1601-6. [Medline].
Cole JD, Blum DA, Ansel LJ. Outcome after fixation of unstable posterior pelvic ring injuries. Clin Orthop. 1996 Aug. (329):160-79. [Medline].
Copeland CE, Bosse MJ, McCarthy ML, et al. Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma. 1997 Feb-Mar. 11(2):73-81. [Medline].
Dalinka MK, Arger P, Coleman B. CT in pelvic trauma. Orthop Clin North Am. 1985 Jul. 16(3):471-80. [Medline].
Gansslen A, Pohlmann T, Paul C, Lobenhoffer P. Epidemiology of pelvic ring injuries. Injury. 1996. 27 Suppl 1:13-20.
Gill K, Bucholz RW. The role of computerized tomographic scanning in the evaluation of major pelvic fractures. J Bone Joint Surg Am. 1984 Jan. 66(1):34-9. [Medline].