4.1 Access

Standard surgical exposures provide anterior and posterior pelvic access (see Chapter 1.6). The Pfannenstiel, extended Pfannenstiel (Stoppa), and low midline exposures are the three most commonly used anterior pelvic exposures [12]. These exposures provide anterior pelvic access from the iliopectineal eminence to the symphysis pubis. For all three, the patient is positioned supine. To elevate the patient from the operating table and also to provide percutaneous posterior pelvic opportunity, a folded operating room blanket or two can be positioned posterior to and in line with the lumbosacral region between the patient and the operating table. For most patients with unstable pelvic injuries, the perineal area warrants significant cleansing including hair removal and topical antiseptics. Once the region is thoroughly cleansed, a topical skin adhesive is applied to the perimeter of the anticipated surgical field and improves adherence of isolation barrier drapes ( Fig 1.8.6-12 ). The penis, scrotum, and urethral catheter are included in the sterile surgical field when combined procedures are planned with the urologists or general surgeons. Antiseptic solutions prepare the skin, and the field is draped. The Pfannenstiel skin incision should be located approximately 2–3 cm cranial to the palpable superior pubis. In obese patients and those with significant displacements so that pubic palpation is not possible, C-arm image intensifier is used to locate the best site for the skin incision. The incision length depends on the extent of the planned work. If the surgeon plans visual and direct access lateral to the midportion of the superior ramus, then the incision should extend to that limit. In male patients, some surgeons prefer to identify and to protect the spermatic cord. Next, any traumatic inguinal soft-tissue injuries are identified, detailed, and explored. Occasionally the traumatic soft-tissue injury provides more than sufficient exposure for repair of the anterior pelvic bone injury. For most patients, the rectus abdominus raphe is identified and incised from the symphysis pubis to approximately 6–10 cm cranially. The rectus abdominus muscle inserts along the cranial and anterior pubic region bilaterally and blends with the thigh adductor muscle origins. The bladder is retracted posteriorly and protected with a malleable retractor, the rectus abdominus insertions are elevated incompletely, and the subperiosteal dissection continues laterally along the superior pubic ramus to the peripheral extent necessary to reduce and stabilize the injury. The pectineus muscles are elevated, if needed, to apply a plate at their site of origin. If the subperiosteal dissection is performed posterior to the rectus abdominus insertions, the inguinal ligament insertions at the pubic tubercles will be elevated as a single soft-tissue unit along with the rectus abdominus incomplete tenotomies. These technical details during the dissection improve the quality of the subsequent soft-tissue closure. It is not necessary to completely tenotomize the rectus abdominus insertion. Muscle relaxation for the patient is provided and maintained during surgery by the anesthesiologist. The benefit of muscle relaxation includes improving retraction′s exposure and making closure easier.

Bladder and urethral repairs by the urologists or general surgeons are best performed prior to the anterior pelvic reduction and fixation. Retracting at the traumatic pelvic injury site usually improves direct surgical access. Once they have completed their repairs, the wound should be irrigated thoroughly and then proceed with anterior pelvic bone reduction and fixation. In some patients, ongoing anterior pelvic bleeding is best controlled by reducing the bone injury first. In these instances the orthopedic portion is prioritized. Since the orthopedic surgeon will usually need a much wider surgical field that includes access to the posterior pelvis for potential percutaneous fixation, the orthopedic surgeon should always position the patient, clean the perineum, drape the operative field, perform the Pfannenstiel exposure that allows both bone and bladder work to occur, and then repair the traumatic and surgical portions of the wound during closure. Wound closure must always include accurate repair of the surgical exposure as well as the traumatic soft-tissue injuries, such as adductor origin avulsions, inguinal fascial disruptions, and rectus abdominus injuries. The extended Pfannenstiel or Stoppa exposure continues the dissection from the symphysis pubis along the posterior surface of the superior pubic ramus to the anterior sacroiliac joint. This exposure provides access to the peripheral pubic ramus’ posterior cortical surface, quadrilateral surface, and greater sciatic notch. Retraction of the bladder posteriorly and retraction of the iliac vessels anteriorly is eased by ipsilateral hip flexion which improves access. Communicating vessels are frequently noted between the iliac and obturator systems at the posterior cortical surface of the superior pubic midramus. These are ligated or coagulated according to their diameter as the dissection proceeds posteriorly. The periosteum of the peripheral superior pubic ramus and quadrilateral surface blend together with the iliopectineal fascia insertion at the pelvic brim. This tissue is incised and elevated. The depths of the Stoppa wound are best illuminated using a headlamp to improve visualization.

The low anterior abdominal midline pubic surgical exposure requires the same patient positioning and draping as for the Pfannenstiel exposure. The low midline skin wound extends cranially from the symphysis pubis approximately 8–14 cm depending on the patient′s size and body habitus. The rectus abdominus muscles is split along the linea alba and incompletely tenotomized as for the Pfannenstiel exposure, so essentially the same anterior pelvic access is obtained. The Stoppa exposure may also be performed with a low anterior pubic midline skin incision. The low pubic midline wound troubles orthopedic surgeons for several reasons. Primarily it is unfamiliar to most orthopedic surgeons or they have been taught that the peripheral anterior pelvic access will be limited compared to the peripheral exposure provided by a Pfannenstiel exposure. The low midline pubic healed surgical scar is more difficult to conceal with clothing and tends to be wider than a Pfannenstiel scar.

The posterior pelvis has three standard surgical exposures. One is performed with the patient positioned supine, while the other two require prone positioning. Accessing the sacroiliac joint with the patient supine uses the anterior iliac surgical interval of the ilioinguinal exposure. The patient is positioned supine as described for the Pfannenstiel approach, but the ipsilateral lower extremity is included in the surgical field so it can be easily manipulated during surgery. Hip flexion is used to relax the iliopsoas muscle and iliac vessels during surgery so they can be retracted easily. The skin incision is parallel to the anterior and middle portions of the iliac crest. At the midpoint of the iliac crest, the incision continues posteriorly and superiorly in line with the external oblique muscle fibers. The dissection proceeds through the fat. Next the surgeon should take the time necessary to identify the interval between the abdominal oblique muscle insertion and tensor muscle origin at the anterior iliac crest. The abdominal oblique muscular insertion is elevated sharply or with electrocautery from the anterior superior iliac spine (ASIS) region and proceeds posteriorly along the crest.

The iliac crest curves posteriorly and superiorly at its midpoint. The surgeon can either follow the dissection along the crest, or incise the external oblique fibers proximally in parallel with their bundles. The internal oblique and transversus abdominus muscle tendon insertions are elevated from the iliac crest at their common tendon insertion that is often noted to be located together with the peripheral iliacus muscle origin. Additional exposure is achieved by extending the dissection medially from the ASIS. First the anterior abdominal fascia is incised approximately 4–6 cm medial to the ASIS and 1–2 cm cranial to the palpable inguinal ligament. The caudal flap is retracted, revealing the lateral portion of the inguinal ligament. That lateral portion of the inguinal ligament is then incised so that it is divided in half, taking care to preserve the lateral femoral cutaneous nerve as it pierces the inguinal ligament in that region. The posterior half of the inguinal ligament is detached from the ASIS in continuity with the prior abdominal oblique insertion elevation in that area.

The iliacus muscle can then be elevated from the cortical bone of the internal iliac fossa. The iliacus and iliopsoas muscle retraction are eased by muscle relaxation, slight hip flexion, and the medial extension of the iliac surgical interval. The deep dissection easily extends from iliac crest to pelvic brim and from anterior inferior iliac spine (AIIS) to the sacroiliac joint. The sacroiliac anterior ligament tissues are elevated from the anterior and lateral cortical surface of the sacrum as needed. Retractor placement and clamp applications protect the fifth lumbar nerve root pathway along the sacral ala and the superior gluteal neurovascular bundle anteromedial to the sacroiliac joint ( Fig 1.8.6-13 ).

Access to the sacrum, posterior ilium, and posterior sacroiliac joint are possible using two common posterior exposures. Both require the patient to be positioned prone. Prone position requires special equipment such as articulated arm supports, head positioners, and padded chest rolls ( Fig 1.8.6-14 ). Blindness after surgery has been noted in patients who are positioned prone due to pressure on their eyes and episodes of hypotensive anesthesia. The genitals, patella, and chin are other common pressure points when patients are positioned prone. Choosing the proper posterior pelvic surgical exposure site is dependent on the injury and the planned procedure.

The posterior midline exposure is familiar to spine and orthopedic surgeons. It provides sufficient exposure of the lumbar spine and sacrum, and the dissection can be extended laterally to include portions of the posterior iliac crests, if needed. The other posterior exposure for pelvic ring injuries is positioned lateral relative to the midline overlying the injured side′s posterior ilium. The skin incision parallels the posterior iliac prominence. The posterior fascia of the gluteus maximus is incised and the muscle is elevated from its origin and retracted laterally. Self-retaining retractors are not recommended since sustained retraction is rarely necessary. These retractors can crush the vulnerable posterior pelvic soft tissues and potentially contribute to wound problems. For posterior iliac fractures and sacroiliac joint injuries, the deep dissection is adjusted to access the injury site and apply necessary fixation devices. For sacral fractures, the deep dissection proceeds medially, the necrotic posterior spinal musculature is debrided, and the posterior nerve roots are preserved whenever possible. In certain sacral fractures, bone fragments are displaced into the sacral tunnels and may be related to nerve root injury. For these patients, the sacral fracture is distracted so the bone fragments can be removed. After reduction and fixation, the lumbodorsal fascia and then the gluteus maximus posterior fascia are repaired. The skin closure is done with tension-relieving sutures to decrease wound-related problems. The skin wound is sealed with a sterile barrier dressing to avoid fecal soiling ( Fig 1.8.6-15 ).

4.2 Instruments and implants

The most important aspects for surgery are reliable colleagues skilled in anesthesia, surgical nursing, and image intensification. The equipment inventory needed for safe and successful pelvic internal fixation consists of a radiolucent operating table, common soft-tissue retractors, narrow diameter wires, reduction clamps designed to accommodate pelvic osseous and soft-tissue anatomy, malleable plates of variable lengths, plate bending/contouring devices, and screws of sufficient diameter and lengths to fit the pelvic osseous fixation pathways. Obese patients may require extra-length retractors, drills, screwdrivers, a fortified operating table, and the best image intensifier unit and technician. Similarly, smaller children may require appropriately sized pelvic implants. The C-arm image intensifier unit and technician must provide high-quality images reliably, and the surgeon must have a complete knowledge of pelvic anatomy, pelvic osteology, and their correlations based on image intensifier.

In the operating room, the C-arm unit is usually positioned on the opposite side from the surgeon. Once the patient is anesthetized and properly positioned, the surgeon may choose to perform a compressive bilateral manual pelvic examination under image intensifier guidance to demonstrate the sites and extent of instability. The overall pelvic reduction due to muscle relaxation, skeletal traction, and other positioning techniques are assessed and adjusted as necessary. The C-arm unit is then positioned to provide consistently reliable images during surgery. The technician and surgeon work as a team to position the C-arm unit while determining the necessary tilts and other adjustments needed for the pelvic inlet and outlet images. At each point, the technician should understand what specific osseous landmarks the surgeon is focusing on for that specific view, and the specific and consistent terminology to be used when referring to each pelvic image. The technician should mark the floor and the C-arm positions needed for each selected view. The marks on the floor and on the C-arm itself improve imaging accuracy and efficiency and decrease overall radiation exposure. During preoperative planning, the necessary intraoperative pelvic inlet and outlet tilts can be estimated on most pelvic CT scans using the midsagittal sacral reconstructed image slice. The midsagittal sacral image will reveal the exact osteology of the midsacrum [13] ( Fig 1.8.6-16 ). The surgeon should share these images and discuss the anticipated C-arm tilts with the x-ray technician prior to surgery. Once the x-ray technician understands the details of intraoperative pelvic imaging and what bone landmarks are important to achieve the desired images, the operation becomes much more efficient, safer, and less stressful. For more complex and bilateral injuries, it may be necessary for the C-arm unit to be initially positioned on one side and then switch to the other side as the surgeon again assembles the pelvic injuries sequentially. The surgeon must be patient with the x-ray technician during the transition and reorientation of the unit. Despite elaborate and often expensive special draping techniques, the lateral sacral image risks contamination of the surgical field as the C-arm unit is positioned. The surgeon helps the technician to position the unit safely prior to lateral imaging so that any wires, clamps, drills, or other devices protruding through the skin that are not easily visible to the technician on the opposite side of the surgical field are not struck accidentally by the C-arm unit. The surgeon and x-ray technician should communicate freely before, during, and after surgery to optimize the intraoperative imaging ( Fig 1.8.6-17 ).

4.3 Reduction (closed, miniopen, open)

Pelvic reductions are accomplished using several standard techniques. External methods include manual manipulation, circumferential pelvic compressive devices, skeletal traction, and external fixation systems. Manual compression and circumferential sheeting are most successful when performed early after injury. Routine anterior pelvic external fixation devices are anchored to the bone using pins placed into the iliac crest and the anterior inferior iliac spine area. Posterior pelvic external fixation devices use sharp pins applied to the lateral cortex of the posterior ilium or the greater trochanter. Access for these devices is percutaneous using appropriately sized incisions. Usually the C-arm image intensifier directs the insertion of small diameter wires first, so the optimal insertion site and directional aim are both established. The wire is advanced into the bone and then the skin incision is made around the wire, and the wire is next exchanged for a drill to open the bone cortex. A cannulated drill can also be used over the initial guide pin, which is highly effective. Depending on the size of the cannulated drill and the planned bone-holding pin, the drill either prepares the entire pathway or simply makes a unicortical opening for the pin to be inserted. Then the bone-holding pin can be inserted through the small but accurately located wound and unicortical bone hole. If the reduction is approved, percutaneous fixation [14, 15] proceeds using iliosacral, superior pubic ramus, and other osseous fixation pathways-medullary screw sites to stabilize the fracture sites ( Fig 1.8.6-18 ).

Percutaneous manipulative devices use sturdy pins inserted into the bone either alone or as a part of manipulation devices attached to the bone pins, such as simple anterior pelvic external fixation, threaded bar compression-distraction devices, or more complicated devices that attach to the operating table.

Closed manipulation of unstable pelvic ring injuries is best accomplished early after injury and is most effective when the contralateral hemipelvis is stable. The sites of injury and their related deformities and displacements are first diagnosed and then detailed on the pelvic imaging studies. Deformity correction is attempted initially using external devices and then percutaneous techniques if necessary. In type C injuries, the injured hemipelvis often has the common multiplanar deformity of external rotation, flexion, distraction, and cranial-posterior displacements. Simple initial reduction techniques, such as manual traction on the ipsilateral lower extremity and pelvic circumferential sheeting, are attempted when the patient is first evaluated during the resuscitation phase. This simple maneuver often reduces the injured hemipelvis well and the manual traction is then exchanged to 4.5–6.8 kg of distal femoral traction. Rarely is more than 6.8 kg of skeletal traction weight needed to achieve satisfactory early reduction. Such traction is also contraindicated for those patients with caudal-anterior hemipelvic deformities ( Fig 1.8.6-19 ).

The skeletal traction is usually applied using a thin diameter wire in the distal femur, attached to a tensioning bow, and then connected to the weight using a simple pulley system on the patient′s hospital bed. The proximal tibia can also be used as long as the knee joint is stable. The optimal traction pin site is selected based on numerous patient and injury variables. Once the patient′s resuscitation renders some form of hemodynamic and overall clinical stability, an operative plan is made to exchange the temporary external reduction aids for definitive internal fixation. In some situations, the reduction achieved by the circumferential sheet and skeletal traction is approximate but the patient′s overall clinical condition may not tolerate a more extensive open pelvic repair. Working portals are made in the circumferential sheet allowing standard anterior pelvic external fixation and percutaneous iliosacral screw fixations [16, 17] ( Fig 1.8.6-20 ).

When the pelvic injury has good overall alignment as a result of the manipulations but has residual distractions at the injury sites, the iliosacral screws are targeted and sequenced to provide compression reduction of the distracted area ( Fig 1.8.6-21 ). Iliosacral lag screws alone rarely provide a perfect reduction but they can be useful during resuscitation to provide early internal fixation and stability [17]. If the manipulative reduction is unacceptable, then the reduction can be revised using open techniques and the fixation adjusted as needed. When postoperative imaging identifies an unacceptable closed reduction result, the iliosacral screws can still be used for definitive fixation since the open reduction will change the screws insertion site.

For certain patients with acute traumatic pelvic instability, circumferential pelvic sheeting accentuates their pelvic deformity but skeletal traction can still provide helpful correction ( Fig 1.8.6-22 ).

More complex multiplanar deformities in types B3 and C injuries may require oblique application of the external manipulating device using pins placed at asymmetrical sites bilaterally. The oblique orientation of the external manipulating device allows correction of the multiplanar deformities ( Fig 1.8.6-23 ).

Successful open reduction is not easy but is best accomplished using well-positioned and sturdy bone-holding clamps according to a detailed surgical tactic. A single reduction clamp, if positioned appropriately, can correct complex 3-D deformities. For the anterior reduction of the sacroiliac joint through an open anterior approach, a large pointed reduction clamp is used. This is placed outside the iliac wing through a small incision over the iliac crest for the posterior or lateral tine, and the ventral tine is place over the anterior lateral sacral ala taking care to avoid the lumbar′s fifth root ( Fig 1.8.6-24 ). This technique allows for the placement of a screw into S2 if the lateral tine is blocking access to S1. Once the S2 screw is placed, the S1 screw can be inserted without fear of losing the reduction ( Fig 1.8.6-25 ). Clamp reduction using a Farabeuf clamp that uses screws to affix it to the bone is also possible from the anterior aspect of the ilium and sacrum. This is effective but has a tendency to open the posterior aspect of the sacroiliac joint if excessive force is applied during the reduction ( Fig 1.8.6-26 ). The Jungbluth clamp is a similar reduction clamp that can be used as well ( Fig 1.8.6-27 ).

Open posterior reductions can be performed from the posterior approach with the patient in the prone position. For sacral fractures, the posterior lateral iliac cortex and the posterior sacral spinous processes are predictable clamp application sites. A routine large pointed reduction clamp is effective but it must be positioned correctly. The deformity obliquity determines these clamp application sites. Commonly the unstable iliac side is secured by inserting the pointed tine into a small drill hole made on the posterior lateral iliac cortex, while the other tine is attached to the stable side on the posterior sacral cortical bone. The sacral spinous processes are good application sites for this clamp but the surgeon must avoid clamp application into the spinal canal area since clamp-related nerve root damage can result. With CT scan, the surgeon ensures that the posterior sacral lamina is intact and fit for any planned clamp application in that area [18–20] ( Fig 1.8.6-28 , Fig 1.8.6-29 ).

Open reduction of iliac crescent fracture with sacroiliac joint disruption is accomplished using either a posterior surgical exposure or an anterior iliac exposure. The posterior exposure is performed with the patient in the prone position, so direct surgical access to the anterior pelvic ring injury is not possible as with the anterior iliac exposure. Regardless of the chosen exposure, the injury site is cleansed and then manipulated under direct vision using a variety of reduction clamps. Using the posterior exposure, a pointed reduction clamp is usually effective with one tine placed through a small cortical drill hole through the lateral iliac cortical bone on the unstable fragment and the other tine is located on the stable posterior iliac crest fragment. A Farabeuf clamp attached with bone screws can also be used to reduce these injuries ( Fig 1.8.6-30 ). If the anterior iliac exposure is selected, the reduction maneuvers and clamp applications are essentially the same as for sacroiliac joint dislocations [21–23].

For sacroiliac joint dislocations treated using a posterior exposure, the clamp is applied for sacral fractures ( Fig 1.8.6-31 ). When the sacroiliac joint is exposed anteriorly, the pelvic reduction or Farabeuf clamp can be positioned using holding screws into the bone on each side of the disrupted joint. Another reduction clamp option is to apply one clamp tine on the anterolateral sacrum avoiding the fifth lumbar nerve root and the other clamp tine through a subperiosteal interval along the lateral iliac cortical bone. Regardless of the clamp type selected, any clamp location must maintain the reduction but not obstruct the fixation [24].