Principles of Management
Mechanism of Injury
Signs, Symptoms, and Initial Management
Imaging and Diagnostic Studies
Classification of Sacral Fractures
Surgical Anatomy and Approaches
Overview of Surgical Approaches
Surgical Treatment of Rami Fractures
Surgical Procedures of the Posterior Pelvic Ring
ORIF Iliac Wing Fractures
Surgical Management of Crescent Fractures (Fracture–Dislocations)
Sacroiliac Joint Dislocations
ORIF of Vertical Shear Fractures
Lumbopelvic Fixation for Spinopelvic Disassociation
Management of Expected Adverse Outcomes and Unexpected Complications
Inability to Achieve Adequate Fixation
Loss of Fixation and Reduction
Postoperative Wound Infection and Dehiscence
Newly Recognized Postoperative Neurologic Deficits
Deep Venous Thrombosis/Pulmonary Embolism Prophylaxis
Author’s Preferred Treatment
Anterior Pelvic Injuries
Posterior Pelvic Injuries
Controversies and Future Directions
Our preferred treatment is for open reduction and internal fixation in cases where the disruption is >2.5 cm, utilizing a 4- or 6-hole locking symphyseal plate. In the nonobese patient, internal fixation is preferred. In the obese patient, wound complications tend to be problematic, and if the patient does not have a large pannus, external fixation is used. They do require vigilant pin care however. We also utilize external fixation in young female patients, especially if future child-bearing desire is indicated. As implants and systems become available for the internal external fixator, our preference would be to utilize this method in all patients in whom ORIF may be problematic. In patients with associated bladder rupture, external fixation is used due to the management of the bladder rupture with nonoperative means. In the event bladder repair is performed, simultaneous ORIF can be considered.
If there are rami fractures in which stabilization is required, antegrade or retrograde screw fixation is used depending on the amount of comminution, bone quality, displacement, and location of the fracture. High pubic root fractures are treated with anterior column screws, whereas more parasymphyseal fractures are treated with retrograde pubic screws. In patients with straddle fractures with significant comminution or osteopenia, anterior external fixation or internal external fixation is preferred.
Closed reduction and percutaneous skeletal fixation with iliosacral screws are preferred if an anatomic reduction can be obtained. Transsacral screws are used in cases when (a) bilateral injuries where sides are reduced easily closed and can be held reduced with pelvic sheeting, and there is insufficient room for two independent screws; (b) poor screw purchase in the sacrum; and (c) SI joint dislocation with contralateral, complete nondisplaced sacral fracture. If there is any issue with obtaining an anatomic reduction closed, then an open reduction via the lateral window of the ilioinguinal approach is used. Percutaneous screw fixation is still the implant of choice.
The preferred treatment is based on the classification based on size: Type I, II or III. The type I crescent is treated with ORIF through an anterior approach. The type II injury requires ORIF through a posterior approach. The type III fracture dislocation will undergo formal ORIF through a posterior approach for screw fixation to the remaining ilium with supplemental SI screw fixation if indicated.
Iliac wing fractures that require operative fixation undergo open reduction and internal fixation via an anterior approach. Occasionally, if the anterior soft tissues preclude incisions, then a posterior approach can be performed.
Complete sacral fractures that are nondisplaced or can be reduced closed with manipulation are treated with percutaneous iliosacral screw fixation. In displaced, complete fractures, posterior fixation is supplemented with anterior fixation in the form of an external fixator to help reduce the stress on the screw. Often, two iliosacral screws will also be used in these cases. If triangular osteosynthesis is warranted, fixation is performed in conjunction with our neurosurgical colleagues. If any neurologic deficit is present and can be correlated with nerve root foraminal impingement secondary to bone fragments based on CT scan or concern for L5 nerve root invagination into the alar fracture and subsequent compression with screw fixation, the patients will undergo decompression and open reduction followed by iliosacral screw fixation. Sacral fractures are approached posteriorly to decompress the sacral nerve roots, whereas the lateral window is used to extract the L5 nerve root from the anterior sacral ala fracture. Transiliac screws are utilized in the following cases: (a) Bilateral complete sacral fractures that are nondisplaced, (b) poor screw purchase within the sacrum, and (c) insufficient room for two screws in bilateral cases.
Two screws versus one screw: The use of two screws is done on a case by case basis and is generally reserved for cases of extensive sacral fracture comminution, significant displacement, and/or poor bone quality. If there is insufficient room for two screws from opposing sides, a second screw opposite the side of the transsacral screw may be placed at the S2 level for added stability. In addition, in cases of sacral dysmorphism, the traditional S1 screw, if it can be placed safely, is placed at an angle up into the ala and it is hoped into the body, but it is usually much shorter. Alar screws have been shown to be biomechanically inferior.160 Thus a second screw is placed in the S2 level to supplement the fixation. However, routinely, the S2 screw will be the first level of fixation in the dysmorphic pelvis.
Spinopelvic instability: In cases of completely nondisplaced sacral fractures that are consistent with true spinopelvic disassociation without kyphosis, a multidisciplinary approach is utilized and discussion with our neurosurgical colleagues occurs. Often, percutaneous iliosacral screw fixation is used in these cases. Otherwise, if spinopelvic fixation is warranted, it is performed by our neurosurgery service in our institution.