1.8.1 Internal fixation of the injured pelvic ring: rationale

10.1055/b-0035-121627

1.8.1 Internal fixation of the injured pelvic ring: rationale

Marvin Tile

1 Introduction

Significant advances have been made in open reduction and internal fixation of pelvic ring disruptions since 1984. The indications and contraindications, what types of pelvic fractures are best suited for open reduction and internal fixation, and the biomechanics of pelvic fixation have been clarified [1–6]. Minimally invasive techniques, especially for posterior pelvic injury, have changed many facets of treatment, including the timing, methods, and overall role of internal fixation, which are discussed in Chapter 1.8.2. Different implants and instruments have been developed as well [7].

What is the reason for the major increase of stabilization of the pelvic ring by internal devices in the past three decades? Prior to 1980, internal fixation of pelvic ring injury was rarely done. Today it is commonplace. There are indications for surgical stabilization in stable types A and B patterns, such as anterior fixation in type B1 (open book) injury and in some type B2 (lateral compression) injuries in polytrauma. In the unstable injury types, it has become the treatment of choice—the conventional wisdom of today [2, 3, 8–12].

Ultimately, any discussion on rationale begs the question: Is it good for patient care? What are the benefits ( Table 1.8.1-1 )? What are the risks ( Table 1.8.1-2 )? The indications are fully discussed further in this chapter.

**Table 1.8.1-1** Benefits of internal fixation.
Obtain and maintain anatomical reduction
Biomechanically more stable fixation
Safer techniques (minimally invasive, guidance systems, and image intensification)
Early mobilization, shorter hospitalization, and improved outcomes fixation.

**Table 1.8.1-2** Risks of internal
General effects of surgery
Complications to nerve, vessel, and viscera
Infection
Failure of fixation

2 Benefits of internal fixation

2.1 Obtaining and maintaining anatomical reduction

In surviving patients with pelvic ring injury, the outcomes are mainly dependent on residual deformity and complications of the injury. Malunion was prevalent prior to treatment with internal fixation, leading to marked leg-length discrepancy and inability to sit ( Fig 1.8.1-1 ) [13, 14]. Although many complications of the injury itself are beyond the control of the surgeon, obtaining and maintaining anatomical reduction by improved techniques of internal fixation is under the surgeon′s control to a large degree, thereby reducing the deleterious effects of malunion, leg-length discrepancy, and nonunion.

2.2 Biomechanics of pelvic stabilizations

In Chapter 1.2, it is clearly noted that external fixation provides insufficient stability to maintain reduction while allowing early ambulation for an unstable pelvic ring injury [15–18]. Depending on surgeon preference, it can be used in the open book fracture (B1, B3.1 or Young-Burgess APC I–II), or in the lateral compression injury (B2, B3.2 or Young-Burgess LC II–III), especially those associated with polytrauma [19]. But for the unstable pelvic ring (type C or Young-Burgess APC III, VS, combined), as noted in Chapter 1.4, external fixators are used mainly for temporary fixation in the acute phase of treatment. When gross deformity is present in an unstable fracture, skeletal traction should supplement external fixation while waiting for the optimal timing of internal fixation ( Fig 1.8.1-2 ).

2.3 Safer techniques

Minimally invasive techniques using guidance systems or real-time image intensification have made the placement of percutaneous screws across the posterior injury much safer for the patient in the hands of an experienced surgeon [7, 20]. Because a posterior incision is eliminated, wound breakdown and sepsis are much less common. These techniques are discussed in detail in Chapter 1.8.2.