2.1.1 Indications

The Pfannenstiel approach ( Video 1.6-1 ) is ideal for exposure and visualization of the pubic symphysis to allow for open reduction and fixation of a dislocation, or for fusion [6]. This approach also may be used to allow for retroperitoneal packing in a hemodynamically unstable patient who has a displaced and mechanically unstable pelvic fracture [7].

2.1.2 Positioning

The patient is placed in the supine position on the radiolucent operating table with the arms typically abducted to 90° on either side. Image intensification is used to confirm that adequate AP, inlet, and outlet views can be obtained before beginning the procedure. Placement of an indwelling urinary catheter is necessary to decompress the bladder to prevent iatrogenic injury during the approach and to allow for identification of the bladder-urethra junction intraoperatively. Muscle paralysis must be used throughout the procedure to ensure that the abdominal muscles are relaxed to improve exposure.

The pelvis is prepared and draped in standard sterile fashion. In some instances, including one or both lower extremities in the surgical field may be beneficial to allow for manipulation and indirect reduction maneuvers.

2.1.3 Exposure

A curvilinear or straight incision is made, centered 2 cm superior to the pubic symphysis and superior pubic rami ( Fig 1.6-1 ). The incision should be centered on the midline and extend just past the external inguinal ring bilaterally. Subcutaneous fat is dissected down to the level of the intercrural fibers of the aponeurosis of the external oblique and anterior rectus fascia. This fascia should be cleared to allow for identification of either the spermatic cord or round ligament.

Alternatively, a direct midline incision can be made extending from the lower extent of the pubic symphysis approximately 10 cm superiorly. This incision is useful when the procedure is being performed in combination with general or urological surgery, or if the patient has a mechanically unstable pelvic fracture and is hemodynamically unstable [7].

The avascular plane of the linea alba can be identified by carefully inspecting the fascia to identify the coalescence of fibers of the external abdominal fascia. The linea alba is then opened longitudinally and extended inferiorly to the pubic symphysis. As the retroperitoneal space is entered, a large hematoma is typically encountered. Care must be taken to avoid injury to the bladder or prostatic venous plexus. The bladder can be identified by direct palpation of the inflated indwelling urinary catheter balloon. A laparotomy sponge and wide malleable retractor are then used to protect the bladder. A Balfour self-retaining retractor is useful to hold the rectus muscles apart and improve visualization of the pubis.

In patients with traumatic injuries, one of the heads of the rectus is often partially avulsed from the pubis. To help with exposure, the remaining rectus attachment should be gently reflected through a subperiosteal dissection. Care is needed to avoid completely detaching the rectus insertion, and the lower fascial attachment should be left in continuity. Subperiosteal dissection can then be continued to expose the anterior and/or posterior aspects of the pubic body. Laterally, the dissection can be taken as far as the iliopectineal eminence ( Fig 1.6-2 ). Exposure of the pubic tubercles bilaterally is useful for the placement of pointed reduction forceps. Alternatively, the reduction forceps can be placed into the obturator foramen. Careful placement of a sharp Hohmann retractor under the superior pubic ramus or into the upper medial corner of the obturator fossa will help retract the recti and improve visualization ( Fig 1.6-3 ).

2.1.4 Closure

Secure repair of the rectus muscles is paramount. In patients with complete avulsion from one or both superior pubic rami, suture anchors loaded with heavy suture may be placed into the body of the pubis and the muscle reattached anatomically. A closed suction drain should be placed into the retropubic space of Retzius before closure. The midline should then be carefully reapproximated. A narrow malleable retractor is useful to avoid iatrogenic bladder injury during closure. The subcutaneous tissue and skin are then closed in a layered fashion.

2.2.1 Indications

The modified Stoppa approach is most commonly used in the treatment of acetabular fractures ( Fig 1.6-4 ), but it also can be used for some pelvic ring injuries [8–10]. It is essentially an extension of the Pfannenstiel approach with additional lateral dissection. This approach provides exposure of both the superior and inferior pubic rami wall lateral to the iliopectineal eminence, as well as exposure of the quadrilateral plate of the acetabulum. It is particularly useful in patients with pelvic malunion in which a rami fracture malunion may have to be taken down to achieve reduction of the pelvic ring.

2.2.2 Positioning

Similar to the Pfannenstiel approach, the patient should be placed in the supine position. An indwelling urinary catheter should be inserted, and image intensification should be used before surgery to ensure that adequate images can be obtained.

The surgeon should stand opposite the injured side. The anterior aspect of the pelvis is prepared and draped in standard sterile fashion. The lower extremity on the injured side should be included in the sterile field to allow for manipulation, and not only to assist with reduction maneuvers. Flexing the hip is often useful as this relaxes the femoral vessels, femoral nerve, and the iliopsoas.

2.2.3 Exposure

The initial exposure is similar to that of the Pfannenstiel approach. Once the superior pubic ramus is exposed, the injured hip should be flexed to relax the neurovascular structures crossing the pelvic brim. Aberrant anastomoses between the obturator artery and/or veins and the external iliac or epigastric vessels (corona mortis) occuring in up to 70% of patients should be located and ligated if encountered [11, 12]. The superior iliopectineal fascia and the inferior obturator fascia are then cleared from the pelvis to expose the lateral pubic rami, pelvic brim, and quadrilateral plate. The obturator vessels and nerve are within the surgical field and must be protected.

This exposure can be combined with the anterior approach to the sacroiliac joint to allow for reduction maneuvers and fixation. Plates can be placed from just anterior to the sacroiliac joint, below the pelvic brim across the quadrilateral plate to the body of the pubis.

2.2.4 Closure

The closure of this approach is similar to that of the Pfannenstiel approach.

2.3.1 Indications

This approach ( Fig 1.6-5 ) is the same as the proximal portion of the extended iliofemoral approach to the acetabulum [13]. It allows direct access to the outer table of the ilium and ischium and is useful in the management of iliac wing fractures, pelvic malunions, and some complex combined pelvic ring and acetabular fractures [2, 14, 15].

2.3.2 Positioning

The patient is placed in a lateral or semilateral position on a radiolucent table with the injured side up. The entire extremity and pelvis including the sacrum is prepared and draped in standard sterile fashion.

2.3.3 Exposure

A curved incision is made from the anterior superior iliac spine (ASIS) along the subcutaneous border of the ilium posteriorly to the posterior superior iliac spine (PSIS). At the proximal end of the incision, the lateral femoral cutaneous nerve is at risk and should be protected [16]. The gluteal muscles and tensor fascia lata are reflected away from the iliac wing. A subperiosteal dissection is completed down to the level of the greater sciatic notch inferiorly and to the sacroiliac joint posteriorly. Care must be taken to avoid injury to the superior gluteal vessels as they emerge from the greater sciatic notch and arborize along the undersurface of the gluteal muscles.

To extend the exposure to include the entire posterior column, the gluteus medius is released from the greater trochanter through either a tenotomy or a greater trochanteric osteotomy [13]. The short external rotators are then carefully reflected from the femur to preserve the blood supply to the femoral head.

The abdominal muscles can be released from the brim of the iliac wing to allow for exposure of the inner table of the pelvis. Dissecting both sides of the iliac wing, however, is associated with a risk of devascularizing the ilium that can increase the risk of nonunion and infection. To minimize this risk, the origin of the sartorius and rectus femorus muscles must be preserved as they contribute a portion of the blood supply to the ilium.