AP Compression

Nonoperative

 

< 2.5 cm diastasis

Stable

Sacrospinous ligament intact

 

MUA APC 2MUA APC 1

EUA of APC-1 injury demonstrating < 2.5 cm instability

 

Instability

 

Sagi et al J Orthop Trauma 2011

- EUA of 14 APC-1 fractures

- 50% deemed unstable and to actually be APC-2 fractures

 

Operative

 

1.  Anterior pelvic ring injury > 2.5 cm pubic diastasis

- anterior plate through Pfannenstiel incision

- anterior external fixation

 

2.  Posterior SI joint disruption

- reduction and posterior stabilisation

- usually with SI screws

- if comminuted may need sacro-iliac plates (anterior or posterior)

 

Pelvic APC ORIF 1Pelvic APC ORIF 2Pelvis APC ORIF 3

 

Pfannenstiel approach / Plating Pubic Symphysis

 

Vumedi video pubic symphysis plate

 

AO surgery reference pubic symphysis plate

 

Technique

 

Set up

- supine on radiolucent table

- foley catheter to decompress bladder

 

Incision 2 cm above pubis

- through fat and fascia

- split linea alba between rectus

- identify and protect bladder

 

Pfannenstiel 1Pfannenstiel 2

Incision 2 cm above pubis                                    Identify linea alba and develop plane between rectus
 

Pfannenstiel 3Pfannenstiel 4Pfannenstiel 5

Identify and protect bladder posteriorly

 

Reduction techniques

- during the reduction care must be taken to avoid trapping bladder or urethra in the symphysis when closing the clamp

- assistant may apply pressure over each iliac crest or an external fixator can be applied

- large pointed reduction clamp can be placed onto each pubic tubercle or through holes drilled in the bone

- expose the medial obturator foramen and application of pelvic reduction forceps thru the medial aspect of the foramen

 

Superiorly applied plate

- pelvic reconstruction plate

 

Pelvis Pubic Symphysis Plate 1Pelvis Pubic Symphysis Plate 2Pubic symphysis plate

Post-operative XRs: AP, outlet and inlet views

 

Outcomes of pubic symphysis plating

 

Morris et al CORR 2012

- 148 patients with pubic symphysis plating

- hardware breakage in 63 patients

- 60% of these patients asymptomatic

- 5 patients required revision for failure of fixation or symptomatic instability

 

Tseng et al Arch Orthop Trauma Surg 2022

- 9 patients with implant failure including plate breakage

- no difference in functional outcomes

 

Baron et al Injury 2021

- 58 patients with APC fractures treated with anterior plate versus anterior external fixation

- Majeed score of 70 with external fixation

- Majeed score of 79 with plate

- non significant

 

Sacro-iliac screws

 

Vumedi video percutaneous SI screws

 

AO surgery reference percutaneous SI screw

 

Technique
 

Radiolucent table with image intensifier

- 45o cephalad and caudal / inlet and outlet views

 

Must reduce SI joint

- reduce vertically with traction on limb / outlet view

- reduce AP usually via anterior plate or external fixation / inlet view

 

Guide wire insertion into body of S1

- anatomic safe zone

- between S1 foramen and superior ala on outlet view (outlet view)

- between neural canal and anterior body  (inlet view)

 

Insert 6.5 mm partially threaded cannulated screw, to aid compression

 

Pelvis Sacroiliac Screws InletPelvis Sacroiliac Outlet

 

Post operative

 

Check screw position with CT

Protected weight bear for six weeks

 

CT SI screwCT SI screw 2CT SI screw 3

 

Outcomes

 

Zwingmann et al Arch Orthop Trauma Surg 2013

- systematic review of SI screws inserted using image intensifier versus navigation

- SI screw malposition in 2.6% cases using inlet / outlet views

- SI screw malposition in 0.1% cases using CT navigation

 

Malpositioned SI screw

 

Khaled et al Eur J Trauma Emerg Surg 2015

- 50 patients with one screw, 37 patients with 2 screws

- no difference in outcomes between one or two screws

 

Kim et al Injury 2020

- systematic review of plates versus SI screws

- no difference in complications or nonunion rates

- implant loosening more common with SI screws

- higher functional outcomes with SI screws

 

Complications

 

L5 nerve root

- injured with anterior cortical perforation with screw

 

Mason et al Eur Spine J 2013

- 55 patients with SI screws

- one patient with L5 radiculopathy

- one patient with S1 nerve root injury

 

Outcomes of APC fractures

 

Lybrand et al J Orthop Trauma 2017

- 35 APC-2 and 19 APC-3

- trends towards between outcomes with ACP-2

- worse outcomes in patients with higher ISS

- worse outcomes with residual displacement > 15 mm

- APC-2: EQ5D 82, Majeed 77

- APC-3: EQ5D 74, Majeed 81