With the development of transportation, severe, high-energy injuries are becoming increasingly common. Pelvic (acetabular) fractures have increased significantly in both their incidence and severity. As a result, pelvic fractures have become a focus of attention for orthopaedic surgeons in the last decade.
The incidence of pelvic fractures is 20-35.2 per 100,000 per year, accounting for 1-3% of bone and joint injuries. Pelvic fractures can cause hemorrhagic shock or other serious complications, and emergency care should first treat life-threatening visceral injuries and complications such as hemorrhagic shock. Since excessive movement of the fracture end can aggravate bleeding, early restoration of pelvic stability and pelvic volume is the basic principle in the treatment of pelvic fractures, especially unstable pelvic fractures.
The operator summarized a total of 53 pelvic fracture surgeries from July 2004 to July 2008, and the experience of various pelvic fracture surgical approaches is as follows.
1.Pubic symphysis approach
①If necessary, the rectus abdominis muscle should be split longitudinally from the white line and not transected.
②When exposing the posterior aspect of the pubic symphysis, care must be taken not to damage the upper urethra and the venous plexus of the bladder and prostate, and this area can often be determined by the large amount of fat around the bladder.
③The plate should be removed in women of childbearing age after complete healing (1 year postoperatively). This is because the ulnar coalition needs to separate naturally during pregnancy and delivery. For adult men, if cartilage loss of the ulnar coalition is found intraoperatively, bone graft fusion is feasible.
④ For unstable pelvic fractures, fixation of the pubic symphysis is only a palliative procedure and must be supplemented with an external fixator to improve the biomechanical strength of the fixation. Otherwise, the injured pelvis does not have sufficient stability to meet the patient for postoperative functional exercise.
2.Iliac inguinal approach
①The affected lower limb is sterilized to facilitate hip flexion during surgery, relax the iliopsoas muscle, and facilitate intraoperative visualization.
②The lateral femoral cutaneous nerve emerges superficially from the medial aspect of the anterior superior iliac spine down to the subcutis, and care should be taken not to damage it during the operation.
③When separating the external iliac vessels, be sure to pay attention to the branches of the closed artery posterior to the vessels. Fingers can be used to touch whether there is tremor, and if there is, it needs to be carefully separated and ligated before the external iliac vessels can be easily retracted. At the same time, when separating the medial external iliac vessels, it is best to separate them slightly medial to the external iliac vessels to avoid damaging the accompanying lymphatics.
④ Do not hold the vessels for too long during surgery, especially in older patients, to avoid damaging the vessels and causing vascular embolism, which can lead to distal limb necrosis in severe cases.
⑤ When separating the medial and lateral interventricular compartments, the interval between the medial and lateral interventricular compartments, which is the thickened iliolumbar fascia, needs to be cut off; otherwise, the medial and lateral interventricular compartments cannot be sufficiently retracted.
(6) After the surgery, the layers of tissue are carefully repaired to prevent inguinal hernia.
3.Anterolateral approach to sacroiliac joint
(i) 1-2 Schanz screws or Stiletto pins can be screwed into the iliac wing intraoperatively to help reset.
②The lumbar 5 nerve root is located 2-3 cm medial to the sacroiliac joint, so be careful not to damage the nerve when stripping and placing the plate during surgery. Only 1 cancellous bone screw is allowed to be screwed into the sacral side of the steel plate; if 2 screws are placed, it is highly likely that the nerve will be damaged.
③Iliac wing fractures are difficult to reset during surgery because the fracture ends are often inserted into each other, and sometimes it is necessary to patiently shake the fracture ends repeatedly until they are loosened to achieve a better reset.
④The anterolateral sacroiliac joint approach is not suitable for treating sacroiliac joint dislocation with sacral fracture.
⑤ This surgical approach is often used in combination with the ilioinguinal approach to treat anterior pelvic ring fractures complicated by sacroiliac joint dislocation.
4.Posterior sacroiliac joint approach
①This incision must avoid the posterior superior iliac spine, otherwise it is prone to flap necrosis and even leads to serious infection. Especially in patients with combined paraplegia, it is recommended not to adopt a flat postoperative position.
②Preoperative bowel preparation should be performed to avoid intestinal pneumatization, which may affect intraoperative positioning.
③When making sacroiliac joint screw fixation, use a Kirschner needle for positioning, and do not use a threaded needle, otherwise it will lack hand feeling when entering.
④When positioning, make sure to take precise pelvic entrance and exit positions. In the entrance position, the anterolateral cortex of sacrum 1 and sacrum 2 overlap and the concave surface of the anterior aspect of the sacrum can be seen. In the exit position, the pubic symphysis is located on the midline of the sacrum and pubic tuberosity. If the exit position and the exit position are not precise, there is a risk that the positioning needle may penetrate the sacrum and injure important nerves or blood vessels.
⑤ When the positioning needle enters, the operator can feel the passage through three zones of resistance. The first is the lateral cortex via the ilium, the second is the iliac side of the sacroiliac joint, and the third is the sacral side of the sacroiliac joint; if the fourth resistance is felt, the entry of the guide needle needs to be stopped.
5.Posterior lateral approach to the hip joint
①Avoid damaging the supra-hip vessels and supra-hip nerves during the operation, especially the vessels should be protected and ligated if necessary, so as not to make the operation difficult due to vascular retraction.
② Pay attention to the prevention of heterotopic ossification. Operate gently during surgery to reduce soft tissue injury, and rinse repeatedly with plenty of saline after surgery. After surgery, 25mg of anti-inflammatory pain can be taken 3 times a day for 3 months, which can effectively prevent the occurrence of heterotopic ossification. If severe heterotopic ossification affects the function of the joint, it needs to be removed surgically, but the recurrence rate after surgery is very high.
③Be careful not to damage the sciatic nerve during surgery.
In addition, there are also iliofemoral approach, enlarged iliofemoral approach and Y-shaped incision, but they are less commonly used in clinical practice because of the disadvantages of heavy injury, more bleeding and longer operation time.
The severity and complexity of pelvic injuries have been widely appreciated in recent years, and great progress has been made in biomechanics, surgical techniques and imaging. Therefore, the surgeon should deeply understand the seriousness of pelvic fracture before surgery, carefully select the surgical plan, strictly follow the surgical indications, and fully prepare the surgical equipment, especially imaging monitoring and neurophysiological supervision, in order to ensure a good functional recovery for patients with pelvic injury.