Lateral Compression

 

LC-1:  pubic rami fracture with sacral fracture

 

LC1 CTSacral fracture

 

Non operative management

 

Beckmann et al J Orthop Trauma 2014

- 27 cases of LC-1 presented to 111 trauma surgeons

- only 9/27 (33%) of cases had substantial agreement on management plan

 

Indications

 

< 1 cm displacement

 

Stable

- incomplete sacral fractures

- no pubic rami fractures

- < 10 mm displacement on lateral stress xray or EUA

 

Stability

 

Indications for EUA / lateral stress xray

- complete sacral fracture with pubic rami fractures

- internal rotation force

- look for displacement of pubic rami fractures

 

Sagi et al J Orthop Trauma

- EUA of 20 LC-1 fractures

- 35% deemed unstable requiring surgery

 

Parry et al J Orthop Trauma 2020

- lateral stress xray with patient in lateral decubitus

- correlates with examination under anesthesia

 

Results

 

Varma et al Cureus 2022

- systematic review of operative versus non operative treatment of unstable LC-1

- all with complete sacral fractures

- 183 surgical and 314 non surgical patients

- surgical patients had lower pain levels

- surgical patients had better quality of life, but non significant

 

Gaski et al J Orthop Trauma 2014

- retrospective review of 50 patients with LC-1 fractures treated non operatively

- all had complete sacral fractures with < 10 mm displacement

- 35/37 patients without other injuries had a good or excellent outcome

 

Soles et al J Orthop Trauma 2012

- 118 patients with LC-1 complete sacral fracture < 10 mm displacement

- all allowed immediate weight bearing

- 1 patient had significant pain and xray signs of displacement at 1 week requiring fixation

 

Operative management

 

Indications

 

> 10 mm displacement

 

EUA / lateral stress view

- complete sacral fracture with instability

 

Technique

 

Posterior fixation

EUA

Anterior fixation if unstable or bilateral pubic rami fractures

 

Results posterior +/- anterior fixation

 

Ellis et al J Orthop Trauma

- 227 patients with LC fractures

- those with oblique or comminuted fractures of the superior and inferior pubic rami more likely to be unstable on EUA

- 11/11 of these treated with posterior only fixation underwent further displacement

 

Avilucea et al JBJS Am 2018

- 74 patients with LC fractures

- EUA following posterior fixation determined need for anterior fixation

- patients with posterior fixation and unilateral rami fractures united without further displacement

- patients with bilateral superior and inferior pubic rami treated without anterior fixation underwent further displacement

 

Posterior fixation

 

Percutaneous sacroiliac screws

 

Posterior approach + / - plates

- highly comminuted

- reduction

 

Percutaneous sacroiliac screws

 

Vumedi video percutaneous SI screws

 

AO surgery reference percutaneous SI screw

 

LC 1 SI screws 1LC 2 SI screws 2LC 1 SI screws 3

 

Posterior sacral plates

 

Technique

- patient prone

- vertical incision 1 cm lateral to PSIS

- from crest to sciatic notch

- incise and reflect G maximus

- apply transverse plate

- soft tissue can be a problem

 

Anterior fixation

 

Indications

- instability following posterior fixation

- bilateral pubic rami fractures

 

Options

- plate - modified stoppa

- percutaneous ramus screws

- external fixation

 

LC with anterior ext fixBilateral pubic rami plate

LC-1 with anterior external fixation                           Plating of bilateral pubic rami fractures

 

LC1 ramus screwRetropubic screws

Percutaneous ramus screw   

 

Vumedi pubic rami screw and IM nail

 

AO surgery reference pubic rami screw

 

AO surgery reference pubic rami plate

 

LC-2:  Pelvic wing fracture with pubic rami fracture

 

LC 2 CT

 

Crescent fracture variant

 

Iliac wing fracture that extends into sacrum and associated with SI joint dislocation

 

Crescent 3Crescent 1Crescent 2

Crescent fracture

 

Non operative management

 

Indications

 

< 10 mm displacement

Stable

 

Results

 

Hagen et al CORR 2016

- 78 LC-2 with < 10 mm displacement treated nonoperatively

- 45 LC-2 with > 10 mm displacement treated operatively

- no difference in pain scores

 

Operative management

 

Options

 

Posterior fixation - iliac plates

 

Anterior fixation

- plate / percutaneous screws / external fixation

 

Anterior versus posterior fixation versus both

 

Zhang et al Int Orthop 2020

- retrospective review of LC-2 fractures

- 44 underwent posterior fixation alone

- 49 underwent anterior and posterior fixation

- increased blood loss and transfusion in AP fixation

- no differences in time to weight bearing, time to union, or functional outcome

 

Iliac fracture plating

 

Pelvic Anterior Sacroiliac Plate 1Pelvis Anterior Sacroiliac Plate 2Pelvis Anterior Sacroiliac Plate 3

 

Technique

- use lateral window of ilioinguinal approach

Vumedi ilioinguinal approach

 

AO surgery reference ilioinguinal approach

 

Outcomes of Lateral Compression Fractures

 

Hammad et al Orthop Traumatol Rehab 2021

- compared 21 surgically treated LC-1 to 16 surgically treated LC-2

- better outcomes and increased return to work in those with iliac fractures compared to sacral fractures

 

Hoffmann et al CORR 2021

- 119 patients with unstable LC fractures treated surgically

- persistent disability the norm

- complicated by high rate of other significant lower limb injuries