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.

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.

2. Posterior Pelvic Ring
transfer load form torso to lower limbs

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”

8. Percutaneous fixation

9. Percutaneous Fixation
Pelvic Osseous Fixation Pathway (OFP)
Tsai C-H
 Safe cancellous pathways for pelvic and certain acetabular
injury fixations
 Geometrically complex ‘‘bone tubes’’ simply corticated bony
cylinders
 For accommodation intraosseous implants screws
 Fill the available pelvic osseous fixation pathway
 Stabilize pelvic and acetabular fractures

10. Pelvic Osseous Fixation Pathway
(OFP)
Tsai C-H
Sacroiliac Sacral
AIIS to
greater
sciatic notch
Posterior
acetabular
column
Inferior
pubic ramus
Superior pubic
ramus/anterior
column
AIIS to posterior
ilium
Gluteus
medius pillar
Iliac crest

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

12. OA/OTA 61B2.2a
Lateral compression fracture of the ilium (crescent) with internal rotation
instability (LC2)

15. Obturator-Inlet

16. Obturator-Outlet

17. Lateral view

18. Pelvic AP view

19. Pelvic Inlet view

20. Pelvic Outlet view

21. /p 1M

22. /p 6M

23. OA/OTA 61B2.2a
Lateral compression fracture of the ilium (crescent) with
internal rotation instability (LC2)

25. Anterior Approach

26. AO/OTA 61B2.2C
Complete disruption of posterior arch, unilateral posterior
injury with iliac fracture and SI disrupture (LC2)

27. ORIF with anterior plate for SI joint
Anterior to iliac wing/SI joint

28. Posterior column involved
Posterior
column fracture
Transverse
fracture T-shape fracture Both-column fracture

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

31. Tranverse fracture, Juxtathecal,
AO/OTA 62- B1.2,left
59 y/o, M

33. Outlet view Pelvic AP view Inlet view

34. /p 2 Ms

35. /p 2 Ms

36. Both column fracture, high variant,
AO/OTA 62- C3.2,left

37. /p 3 Ms

38. /p 5 Ms

39. Both column fracture, low variant,
AO/OTA 62- C2.2, right

40. Well articular reconstruction , no screw
penetration

41. /p 8 Ms : AVN of femoral head

42. Severe Cavitary Defect
Paprosky Type III A Defect
THA + Impaction Bone Grafting

43. Lumbaopelvic Fixation

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

49. Minimal invasive Triangular Osteosyndesis
Sacral fracture ,Type C3
displaced U-type fracture,M3,N3,

50. /p 1M

51. /p 4 Ms
/p 3 Ms

52. Pelvic+ sacral fracture, Vertical type

53. AO/OTA 61C1.3C
complete disruption of posterior arch, unilateral posterior injury
(APC3, vertical shear)

54. Post-op 2 weeks

55. Post-op 6 weeks

56. Post-op 10 weeks

57. 標題
Post-op 20th weeks

58. 61C3.3e Complete disruption of posterior arch,
bilateral posterior injury, both sides complete disruption
(APC3, vertical shear)

59. Staged reconstruction : 1st supine,2nd prone,3rd lateral
decubitus
Sacral+ ant. Pelvic ring+ acetabulum

61. /p 4 Ms

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

65. FFP I
isolated anterior lesion
FFP II
Un-displaced posterior lesion

66. FFP III
Displaced unilateral post. lesion
FFP IV
Displaced bilateral post. lesion

67. FFP IV : Displaced bilateral posterior lesion
Insufficiency fracture

68. FFP IV : Displaced bilateral posterior lesion
Bil. Percutaneous screw fixation + Ant. MIPO

69. /p 2Ms

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

71. 2018/4/172
Thanks for your attention!!