Posterior Pelvic Injury need correct squeal procedure reduction and fixation.Here we hare our experience in China Medical University Hospital , Taichung,Taiwan. This topic also presented in the meeting in TOA.
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Surgical Management of Posterior Pelvic Ring Injuries
1. SURGICAL MANAGEMENT OF POSTERIOR
PELVIC RING
Chun-Hao Tsai, MD
中國醫藥大學 附設醫院
骨科部 蔡俊灝 醫師
Associate Professor
Department of Orthopedic Surgery, China Medical University Hospital,
Taichung, Taiwan, R.O.C.
3. Sacrum
SI joint
Posterior column-(wall) of
acetabulum
Posterior Pelvic
Ring
4. Outline
Surgical treatment of posterior ring (our case)
Posterior Percutaneous fixation
Anterior SI fixation
Posterior column involved
Spinal-pelvic fixation
Sacral+ ant. Pelvic ring+ acetabulum
Fragility fracture of the pelvic ring
5. Fixation of pelvic Ring-
Letournel’s golden Rule : Posterior Ring First
Posterior stability must be re- established
Except with APC2 injury
Symphysis dislocation with no breaks in the innominate bone
Anterior ORIF not reduce posterior the posterior ring injury
Anterior fixation the key for rotationally unstable injury
Posterior fixation is the key for globally unstable
Appropriate sequence and position is important
6. Indication for fixation of posterior ring injury
6
Posterior instability
Displaced iliac wing fx extended to the crest, greater sciatic
notch or SI joint (crescent fx )
SI ligament disruption
Non-impacted / comminuted sacral fractures
Propensity for cephalic(vertical) displacement
U-shape sacral fracture with spinal-pelvic dissociation
7. Surgical treatment of posterior ring
Percutaneous fixation
Posterior ORIF
Anterior ORIF
Iliosacral screw
SI plate(90 degree)
Combination
Lag screw for “crescent”
11. Posterior Approach
Direct reduction of
dislocation
Avoid L5 nerve root
Ease of insertion of SI screw?
Prone posterior
Two stage if anterior fixation
required
Soft tissue
Superior gluteal artery
Advantages Disadvantages
29. Classification of transverse family
Location with respect to roof
Transtectal, juxtatectal ,infratectal
Orientation of the transverse fracture
Displacedment of the ischiopubic segment
Displacement of the femoral head
Posterior?
Central?
Characteristics of the associated post. wall presence and
location of the vertical stem (T-shaped)
30. Both-Column(BC) fractures
Proximal-to-distal rule
Intrapelvic approach + iliac windows
1. Reduce iliac wing fragment
2. Fixation with lag screw near crest or plate at the inner surface of iliac
crest
3. Fixation of AC fracture line with short plate (screw)
4. Hook plate for AC-Quadrilatral plate
5. Definitive fixation of AC
6. PC
1. Intrapelvic approach or iliac window approach with PC screw
2. or staged Posterior KL approach
外
內
44. Indication for lumbopelvic fixation
H-shaped sacral fractures with spinopelvic dissociation
Comminuted uni-or bilateral vertical sacral fractures
AP pelvic ring disruption with vertical and cephalic instability
Non-impacted / comminuted sacral fractures with external rotation
deformity of hemipelvis
U-shape sacral fractures with spinal dissociation ,cauda equina
syndrome, or excessive sacral kyphosis
Impacted sacral fractures form lateral compression injury with
excessive internal rotation and pelvic deformity
Failed primary fixation (loss of reduction)
45. Lumbopelvic Fixation
Concepts of 3 zones
O’Brien MF, spinal deformities ,2003
Zone I : S1 VB and cephalic margin of
sacral Ala
Zone II : inferior margins of sacral Ala ,s2 to
tip of coccyx
Zone III: Bilateral Ilium
46. Spinal-pelvic fixation construct
46
Lumbopelvic fixation or Triangular osteosynthesis
Severe comminution
osteoporotic bone
Disruption of the L5/S1 facet joint
Bypassing the sacral fracture with fixation
the lines of force transmission form the spine to the ilium
travel through the fixation instead of sacrum
47. Lumbopelvic reduction and fixation technique
Fracture reduction
Simultaneous correction of
AP displacement of
hemipelves in to a dorsal
direction by manual
traction with a second pair
of reduction clamps
Manual traction form both
legs and hyperextension of
hip joints
L4/5 pedicle screws
Iliac screw
48. H-shaped sacral fr with an anterior pelvic ring injury
The deformity of the entire pelvic ring increase in complexity
with the addition of an injury in the anterior pelvic ring
Frequency of an anterior pelvic injury 52~78%
Steps
1st reconstruction of the anterior part of the pelvic ring
ORIF with plate for rami fx
2nd posterior lumbopelvic fixation
62. Fragility fracture of the pelvis
Fragility fracture of the pelvis
Calcif Tissue Int (2015) 97:577–580Low-Trauma Pelvic Fractures in Elderly Finns in 1970–2013
63. Fragility fracture of the pelvis: characteristics
Low energy trauma
Collapse instead of explosion
Creeping loss of stability over time
Weak cortical and cancellous bone- Ligament rigid
Bone fails between intact ligaments
Specific fracture morphology(sacral ala, bilateral)
New entity
Tile, AO/OTA, Young/Burgess Classification no reflect fracture
morphology and trauma mechanism
64. Comprehensive classification of fragility fracture of the pelvic ring
(FFP)
FFP I isolated anterior lesion
FFP II Un-displaced posterior lesion
FFP III Displaced unilateral posterior lesion
FFP IV Displaced bilateral posterior lesion
posterior pathology is missed easily by only x-ray , so CT of
pelvis is indicated in isolated pubic fx in elderly
FFP IVb (which with scaral transver fx, H type sacral fx )is high
percentage
70. Take Home message
Posterior pelvic ring injury
High energy injury
ACLS
Staged damage control surgery
Team work
MIS
Low energy –geriatrics
Growing population
Same principle ?
Comorbidity