1.8.3 The management of the injured pelvic ring: internal fixation of stable pelvic ring fractures (type A)

10.1055/b-0035-121629

1.8.3 The management of the injured pelvic ring: internal fixation of stable pelvic ring fractures (type A)

Markku T Nousiainen, Philip A Brady

1 Patient selection/indications

Although stable pelvic ring fractures (type A) do not lead to instability of the pelvis, there are certain instances when such fractures may require internal fixation. This usually occurs with a displaced fracture that is associated with significant pain, disability, or even neurological compromise. Although most type A1 avulsion fractures can be treated nonoperatively, those that are significantly displaced (> 2 cm) may require open reduction and internal fixation (ORIF) to minimize pain and restore function, especially in athletes [1, 2] ( Fig 1.8.3-1 ). Type A2.1 iliac wing fractures may also be treated nonoperatively, but ORIF is beneficial to minimize pain and cosmesis if significant displacement occurs ( Fig 1.8.3-2 ). Type A2.2 undisplaced or minimally displaced pelvic fractures do not require surgery, but such injuries must be carefully assessed so as not to miss occult instability. Type A2.3 isolated anterior ring injuries benefit from ORIF when significantly displaced (as this can lead to nonunion) or if associated with an ipsilateral femoral artery, vein, or nerve injury (to minimize irritation on the neurovascular bundle; see Chapter 1.9). For type A3 sacral and coccygeal fractures, only symptomatic, displaced A3.1 coccygeal or sacrococcygeal fractures/fracture-dislocations or A3.3 displaced transverse sacral fractures that cause significant neurological deficit require operative intervention (decompression with or without stabilization) ( Fig 1.8.3-3 ).

Concern should be raised for the presence of a pathological fracture in adults who present with an avulsion fracture of the pelvis without a history consistent with trauma. A thorough workup should always be performed to rule out the presence of metastatic or primary bone tumor.

**Fig 1.8.3-1a–b** A 16-year-old athlete with type A1 avulsion fracture [2]. a Preoperative AP pelvic x-ray of a left ischial tuberosity avulsion fracture. b Postoperative AP pelvic x-ray showing anatomical reduction of the fracture fragment. (With permission from Lippincott Williams & Wilkins).

**Fig 1.8.3-2a–b** a Preoperative AP pelvic x-ray showing a displaced left iliac wing fracture. b Postoperative x-ray after open reduction and internal fixation with two 3.5 mm lag screws.

**Fig 1.8.3-3a–c** a E xample of a displaced, transverse sacral fracture below the level of S2. **b–c** Sacral laminectomy with nerve root decompression, and plate stabilization was performed because of a sacral plexus lesion.

2 Nonoperative management

Excluding the instances listed previously, most type A fractures are treated nonoperatively. Adequate pain management, deep vein thrombosis prophylaxis, and appropriate physical therapy are important to maximize the patient′s mobility during the healing process. With a stable pelvic ring, patients may bear weight as tolerated and do gentle, progressive range-of-motion exercises. Once adequate healing has occurred (between 8 and 12 weeks), progressive strengthening, proprioceptive, and gait-training exercises ensue.

3 Preoperative planning

All patients with pelvic fractures who will undergo surgical management must have adequate x-rays (AP pelvis, inlet, and outlet views) and a computed tomographic (CT) scan so that the surgeon can exactly determine the location and extent of the injury. Magnetic resonance imaging should be ordered in cases of A1.1 apophyseal avulsion fractures in adolescents if the lesion is occult radiographically ( Fig 1.8.3-4 ) [3]. A long, radiolucent table, a large C-arm, a pelvic external fixator set, reduction forceps, and appropriate internal fixation instrumentation set should be reserved for surgery.

4 Surgical techniques

4.1 Access

Avulsion fractures of the pelvis involving the anterior superior iliac spine (ASIS) or anterior inferior iliac spine (AIIS) (types A1.1 and A1.2, respectively) may be approached from a modified ilioinguinal (lateral window) or Smith-Petersen approach. Avulsions of the ischial tuberosity (type A1.3) are approached from a Kocher-Langenbeck or gluteal crease approach [2]. Isolated iliac wing fractures (type A2.1) are approached from a modified ilioinguinal (lateral window) approach. Isolated anterior ring fractures (type A2.3) can be accessed by a small incision adjacent to the symphysis pubis, through which percutaneous screws can be placed in a retrograde method along the superior pubic ramus into the anterior column. If an open approach is needed to manage a nerve or vessel injury, then a Pfannenstiel, Stoppa, or ilioinguinal approach can be used to access the fracture.

Coccygeal fractures/sacrococcygeal dislocations (type A3.1) or displaced transverse sacral fractures (type A3.3) are approached through a posterior midline sacral exposure.

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