Indications for anterior fixation of pelvic fractures

From April 1982 to August 1995, the author treated 127 patients with pelvic ring injuries by open reduction and internal fixation within 3 weeks of injury. Fifty-five (43%) patients (none of whom had a symphysis dislocation) had posterior internal fixation without anterior pelvic internal or external fixation. In 37 patients (29%) anterior and posterior internal fixation was performed whereas 35 patients (28%) were treated by anterior internal fixation alone. Plates and screws were used for all anterior fixations. Bladder or urethral injury was not considered a contraindication to anterior internal fixation. Of 109 patients who were observed until union of their fractures, 3 required a repeat surgery because of loss of reduction or failure of fixation or both. All 3 patients maintained reduction and healed after the second intervention. Of 72 anterior internal fixations, 1 deep infection was the only surgical complication. A single plate is reliable for fixation of the symphysis pubis and when necessary, the superior pubic ramus. However, even in displaced and unstable pelvic ring injuries, most fractures of the pubic rami do not require stabilization by internal or external fixation. Eighty-eight of 105 fractures of the obturator ring were not internally fixed and none required subsequent treatment for nonunion or loss of reduction; nor did their initial instability cause failure of posterior fixation. Internal fixation of the anterior pelvic ring, though safe and reliable, should be reserved for symphysis pubis dislocations and only a minority of pubic ramus fractures.