Iliosacral screw fixation of the unstable pelvic ring injuries

To report on the early results and possible complications of iliosacral screw fixation in the management of unstable pelvic ring injuries.

One hundred and two unstable pelvic ring injuries were treated using iliosacral screw fixation for posterior pelvic ring disruptions. Closed manipulative reductions of the posterior lesion were attempted for all patients. Open reductions were used in the minority of patients with unsatisfactory closed reductions as assessed fluoroscopically at the time of surgery. Anterior fixations were by means of open reduction in 62 patients and by external fixation in 14 patients, and by screws in 7 patients. Twenty patients had no anterior fixation. Plain anteroposterior, inlet and outlet radiographs of the pelvis were obtained postoperatively at six weeks, three months, six months and one year. A pelvic computed tomography scan was performed postoperatively in those patients where residual displacement or screw misplacement was suspected. Complications were recorded.

One patient died 31 days after the trauma due to pneumonia and one died 9 months after the surgery after a fall from a height in a second suicidal attempt. There were two posterior pelvic infections and one anterior pelvic infection. Screw misplacement occurred in seven cases. In six cases a misplaced screw produced transient L5 neuroapraxia. There was no fixation failure requiring revision surgery. There was one case of injury to the superior gluteal artery.

Unstable pelvic ring disruptions are severe injuries, associated with a high rate of morbidity and mortality. Pelvic fractures can be treated by variety of methods. Treatment with traction and pelvic slings does not offer accurate reduction and confines the patient to prolong bed rest with all potential complications. Several authors documented lower morbidity and mortality rates and shorter hospital stay in patients treated by early operative stabilization of pelvic injuries. The timing of the surgery is still controversial. Some authors in large trauma centres believe that ideally the initial treatment should be the final treatment. The advantage of urgent fixation is the use of this usually minimally invasive technique in the initial stabilisation of a hemodynamically unstable patient.The disadvantage is performance of the surgery under increased stress and time limit, which may lead to the acceptance of sub-optimal reduction. Very good team work of the orthopaedic surgeon, anaesthetist and other involved specialists (general surgeon, urologist) is necessary.

Iliosacral screw fixation is a useful method of stabilizing unstable pelvic ring injuries. It is a difficult technique, with a steep learning curve. The surgeon must understand the complex and variable sacral anatomy. High quality fluoroscopic imaging is a must. Especially in vertically unstable injuries the sacroiliac screws need to be augmented by sound anterior fixation. Low rates of infection, wound healing problems and minimal blood loss are advantages of this method.