Traumatic pelvic ring injuries have become a major concern. Previously, orthopedic knowledge held that patients who suffered pelvic ring injuries and survived had no residual long-term sequelae from their musculoskeletal injuries. However, recent studies have indicated that patients with unstable pelvic ring injuries are better treated with surgical fixation. In addition, fracture fixation improves long-term functional outcomes of pelvic injuries. Pelvic injuries have a mortality rate of more than 10%, of which 4% is due to pelvic hemorrhage. Vertically stable bony pelvic injuries, which account for approximately 65% of the total, generally do not require fixation surgery.
I. Classification
1, according to the degree of integrity of the pelvic ring points.
① pelvic ring remains intact.
② single fracture.
③Two or more fractures.
2. According to the degree of pelvic stability (Tile 1988), there are three types: type A is stable, with slight displacement and generally not affecting the pelvic ring; type B is rotationally unstable; and type C is vertically unstable. Displacement of the hemipelvis in the vertical plane in a posterior to cephalad direction may occur only when the sacroiliac complex and pelvic floor suffer disruption.
Type A – stable type with slight displacement
A1: no involvement of the pelvic ring.
A2: there is mild disruption and displacement of the pelvic ring, such as a fracture of one pubic branch.
Type B – with rotational instability, but longitudinal stability
B1: opening of the book page pattern.
B2: lateral compression on one side, such as a fracture of the pubic body
B3: contralateral lateral compression in a barrel-handle pattern.
Type C – rotational and longitudinal instability
C1: dislocation of the sacroiliac joint on one side and separation of the pubic symphysis
C2: bilateral sacroiliac joint dislocation and separation of the pubic symphysis
C3: with acetabular fracture.
II. Treatment
(A) Trapezoidal compression brace repositioning for pelvic fracture Pelvic fracture or fracture-dislocation rarely requires incision and internal fixation, and generally excellent results can be achieved through bed rest, pelvic pocket, brace and bone traction. In order to reduce the time of bed rest and to promote the early landing, the application of external fixation brace has been advocated in recent years.
Indications: One or bilateral fracture with sacroiliac joint dislocation and separation of the pubic symphysis.
For sacroiliac joint dislocation of more than 1 cm, lower limb bone traction can be performed first, and AO screw fixation can be given after satisfactory repositioning.
(B) Internal iliac artery ligation
Indications: Severe bleeding from pelvic fracture causing hemorrhagic shock with bleeding volume up to 2000-4000 or more, and the patient’s blood pressure cannot be maintained despite rapid blood transfusion and fluid resuscitation.
Anesthesia: Epidural crestal block or endotracheal intubation with combined inhalation and intravenous anesthesia.
Position: supine position with head low and foot high.
Modality: transperitoneal cavernous internal iliac artery ligation, transperitoneal external internal iliac artery ligation.
(iii) Treatment of pelvic fracture with external bone fixator
History of development: It was pioneered by Carabalona (1973) in the 1970s, and Slatis (1975), Carabalona (1978) and Broo (1979) reported satisfactory results in the treatment of unstable pelvic fractures.
Advantages: The external bone fixator is given for fixation while resuscitating shock and multiple injuries, which stabilizes the fracture, controls bleeding, and allows simultaneous treatment of the fracture and multiple injuries.
Indications.
1, anterior-posterior extrusion type of pelvis (such as bilateral pubic branch fracture, pubic symphysis separation), lateral extrusion type (such as iliac fracture, hemipelvic dislocation, pubic symphysis overlap) and vertical shear type fracture (such as unilateral sacroiliac joint dislocation).
2, Unstable pelvic fractures with open fractures of the extremities and multiple injuries.
3, pelvic fracture dislocation combined with visceral injury, multiple fractures and shock.
Contraindications: bilateral vertical shear pelvic fractures (such as bilateral sacroiliac joint dislocations), pelvic comminuted fractures.
(D) Sacroiliac joint fracture dislocation with percutaneous compression threaded nail internal fixation
Pelvic fracture typing: Based on the anterior-posterior pelvic position, entrance X-ray and CT scan, the fracture is divided into 4 types.
1.Type I Sacroiliac joint dislocation and pubic bone fracture or pubic symphysis separation, resulting in hemi-lateral pelvic dislocation.
2.Type II Sacral body or flank fracture and pubic bone fracture or pubic symphysis separation, resulting in hemipelvic dislocation.
3.Type III: Posterior sacral fracture and pubic bone fracture or separation of pubic symphysis, resulting in hemipelvic dislocation.
4.Type IV: Sacral and iliac bone fracture with anterior ring injury, resulting in hemipelvic dislocation.
Indications: Type I to IV pelvic fracture dislocation, treated with external pelvic bone fixator or failed with other methods.
Contraindications.
1.Comminuted fracture of the lateral sacral flank or sacral vertebral body in type II.
2. Posterior iliac fracture through the olecranon facet in type III.
Special instruments.
1.Wrench, including two parts, the outside is the sleeve and the inner surface is the sleeve rod.
2, Hollow pressurized screw.