40: Pelvic External Fixation

PROCEDURE 40 Pelvic External Fixation



William N. Dust, Trevor B. Stone



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Indications




PITFALLS



• Iliac wing fractures.

• As definitive stabilization of vertically unstable pelvis fractures.

• Pin/frame placement may complicate surgical approach/positioning in patients with concomitant pelvic ring and acetabular fractures.


image Temporary stabilization of pelvis fractures in hemodynamically unstable patients as part of resuscitation

image Stabilization of pelvis fractures in polytrauma patients to relieve pain and allow early mobilization to an upright position

image Definitive stabilization of certain rotationally unstable, vertically stable pelvis fractures

image Definitive treatment of the anterior pelvic ring in type C injuries for instability following posterior internal fixation

image Adjunct anterior stabilization of internal fixation


Examination/Imaging




Controversies



• Will a sheet/binder work as well as external fixation in the unstable patient and be quicker and easier to apply?

• Where to apply external fixation: in the emergency room or the operating room?

• When to apply it: before or after laparotomy?

• Should external fixation be used in “stable” lateral compression fractures in multiple polytrauma patients to allow early mobilization.



Treatment Options



• Pelvic sheeting/binder in hemodynamically unstable patients with external rotation and vertically unstable fractures

• Internally rotating and strapping together the lower extremities in hemodynamically unstable patients with external rotation and vertically unstable fractures

• Pelvis C clamp in hemodynamically unstable patients with external rotation and vertically unstable fractures

• Open reduction and internal fixation or percutaneous fixation of pubic rami fractures and/or symphyseal diastasis as definitive treatment of the anterior pelvis injury

• Military antishock trousers in hemodynamically unstable patients; however, their use has become controversial


image Gentle physical examination is performed to determine internal/external rotational instability and vertical instability.

image The patient is assessed for associated urologic, bowel, or acetabular injuries to guide choice of external fixation.

image An anteroposterior (AP) pelvis radiograph is usually sufficient in hemodynamically unstable patients.
• Figure 1 shows a vertically unstable fracture (type C2) in a hemodynamically unstable polytrauma patient (Case 1).

• Figure 2 shows an AP view of a compression fracture with unstable external rotation, but stable vertically (type B1) (Case 2).

image A computed tomography scan with or without inlet and outlet pelvic radiographs is used to determine definitive treatment.
• Figure 3 shows a lateral compression fracture with locked symphysis (type B2) (Case 3).

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FIGURE 1


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FIGURE 2


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FIGURE 3



Surgical Anatomy



image Pin placement in the iliac crest insertion between the anterior superior iliac spine (ASIS) and iliac tubercle (Fig. 4)
• The curvature of the crest and obliquity of the ilium must be taken into consideration so that the pins converge in the dense bone proximal to the acetabulum.

• Structures at risk include
♦ Lateral femoral cutaneous nerve in the region of the ASIS

♦ Hip joint (by deep insertion of the pin)

image Supra-acetabular (anterior) pin placement between the ASIS and anterior inferior iliac spine (AIIS) (Fig. 5)
• Structures at risk include
♦ Lateral femoral cutaneous nerve

♦ Hip joint (by misdirected pin)

♦ Femoral nerve and vessels

♦ Sciatic notch (if pin is inserted too far)

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FIGURE 4


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FIGURE 5




PEARLS



• The lower abdomen and proximal thighs should be prepped.

• Consider free draping of the lower extremity in vertically unstable fractures.



Equipment

Related posts:

16: Perilunate Injuries 1: Open Reduction and Plate Fixation of Displaced Clavicle Fractures 7: Supracondylar Humeral Fractures 18: Femoral Neck Fractures: Arthroplasty 8: Terrible Triad Injuries of the Elbow 5: Humeral Shaft Fractures

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Jun 7, 2016 | Posted by in ORTHOPEDIC | Comments Off on 40: Pelvic External Fixation

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